My 8 month old Wirehaired Pointing Griffon was just diagnosed with SRMA 2 weeks ago. We are treating with Prednisone and are seeing great results. I have no doubts that he has SRMA but I am trying to research the correlation of the following factors present at time of diagnosis:
In his CSF sample he had very high WBC. At time of diagnosis he was fighting yeast infection in both ears.
I am very curious to hear from other owners whose dog has SRMA. I am interested in finding out if you also saw elevated WBC in the CSF and if your canine had any infections at time of diagnosis.
Thank you!
Have you seen this? : http://cimda.co.uk/smf/index.php?topic=25.0 It mentions elevated WBC.
Also if you put SRMA in the search function you will see several posts from owners with dogs with SRMA.
Hi and welcome.
I am sorry that your young boy has SRMA. The good news is, SRMA responds very well to immunosuppressive treatment, as you have witnessed. I do hope the immunosuppressive protocol that he is on is a good one because this is crucial if it is to bring SRMA into remission.
Elevated WBC's are seen not only with infections but with an inflammatory autoimmune disease, so this is quite usual. Also, I have known dogs with an inflammatory AI disease to have yeast ear infections too. So it is very likely to be connected.
http://www.theveterinaryexpert.com/ear/ear-disease-in-dogs/
Autoimmune diseases (where the immune system attacks the cells of the body)
These diseases are all very rare, and usually cause skin disease at other body locations too. However, they can result in inflammation in the ear canals and result in ear disease.
Jo
Jo - Thank you very much for your response. I am glad you included the information about the ear infection. I had not thought of it as a connection, only as a "trigger".
I have seen some posts here about the prednisone/ other steroid protocols. The prednisone regiment he is on follows very closely to what is illustrated here: https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1939-1676.2009.0337.x
It is scary to think about the terrible side effects of prednisone but it is good to know that the higher dosage does not improve clinical outcome and therefore is not necessary. The study conducted by NC State has some great information as well. I didn't know that Wirehaired Pointing Griffons had a predisposition to this disease before reading the results: https://onlinelibrary.wiley.com/doi/full/10.1111/jvim.15543.
@Jo - I was talking in a facebook group and thought I should post here as well. My Dog's spinal fluid sample was not sent out for culture when it was collected. I did not find out that this should have been until it was too late. I am unsure how to feel. I know that bacterial meningitis could have been missed. He is doing well on the prednisone. If if diagnosis of SRMA were incorrect, wouldn't he be getting worse?
Thank you in advance for any insight or thoughts you can provide.
Hi
SRMA, as the name suggests, responds very well to immunosuppressive doses of prednisolone and the improvement in clinical signs can be seen within 24 hours. SRMA is an inflammatory disease not a bacterial or viral disease.
Bacterial meningitis is not treated with immunosuppressive doses of prednsiolone, it is treated with antibiotics to kill the bacteria and clear the infection. The two have an entirely different disease process. SRMA has no underlying cause, other than a genetic predisposition, but in bacterial and viral meningitis the underlying cause, such as bacteria, has to be treated otherwise no improvement in clinical signs will be seen.
Given that your boy has responded so well to the immunosuppressive treatment, I don't think you should have any concerns about it being anything other than SRMA. You should not be charged for the spinal tap, if the sample wasn't sent off for analysis. The positive response to treatment assumes SRMA.
I do hope a good, steady protocol is followed because it is not uncommon for dogs with SRMA to relapse and immunosuppressive treatment has to be started all over again. Sometimes taking the last stages of treatment slowly, as long as the side effects allow, gives a better outcome. SRMA has an excellent prognosis.
Fingers crossed.
Jo
Thank you again! This is very helpful information.
His prescribed steroid protocol is this: (He weighs 20kg and the tablet is 20mg)
-Give 2 tablets by mouth every 12 hours for 1 week, (this was decreased to 5 days after adverse reaction of bloody vomit)
-the give 1 tablet by mouth every 12 hours for 6 weeks, (we are on week 5 of this)
-then give 1 tablet by mouth every 24 hours for 6 weeks,
-then give 1/2 tablet by mouth every 24 hours for 6 weeks,
-then give 1/2 tablet by mouth every 48 hours for 6 weeks, then discontinue
Hi
There are many different immunosuppressive drug protocols. Some are excellent and others are not so good, and others are not good at all.
The best immunosuppressive protocol that I have come across is by Prof Michael J Day. Over the years I have found that this protocol is able to produce sufficient immunosuppression to bring the disease under control, and it limits the risk of unacceptable side effects. Also, by reducing by 25% each time anecdotally, remission is achieved more often. All protocols should be tailored to the individual and altered if side effects deem it necessary. See below:
Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition, by Michael J Day
Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS
Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose Duration (based on clinical effect)
1.0mg/kg/q 12h 10-28 days
0.75mg/kg/q 12h 10-28 days
0.5mg/kg/q 12h 10-28 days
0.25mg/kg/q 12h 10-28 days
0.25mg/kg/q 24h 10-28 days
0.25-0.5mg/kg EOD at least 21 days
0.25-0.5 mg/kg every third day at least 21 days
Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.
Prednisolone: "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight." Plumb's Veterinary Drug Handbook Eight Edition.
I hope your boy is on something to protect his stomach from the excess acid that the steroids produce, such as omeprazole. If he isn't then he should be, so I would check with your vet.
Jo
I will post a few tips about what to expect when treatment has started.
WHAT TO EXPECT ONCE IMMUNOSUPPRESSIVE TREATMENT HAS STARTED
If a dog has a serious autoimmune disease, then the sooner treatment commences the better chance the dog has of survival. The main delay to starting treatment is obtaining a diagnosis or at least your vet being sure that he hasn't missed anything that could be made worse by giving high doses of steroids. Achieving a diagnosis can be a fight against time.
If your vet has decided that in all probabilities your dog has an autoimmune disease, then to a certain extent, which autoimmune disease your dog has, as far as treatment is concerned, is irrelevant because with the exception of a few diseases, they are all treated the same, that is, with immunosuppressive drugs. The main objective is to 'knock out' the immune system and virtually stop it from working (or near enough) so the destruction will cease and give the body a chance to recover. As previously stated, this treatment regime works in most cases, that is, if it has been given early enough and the dosage is correct. All dogs are different and some can tolerate the drugs better than others. In proportion to their size, small dogs seem more able to tolerate higher doses of steroids than large ones. Some diseases are more serious than others and carry a poorer prognosis. So the initial crisis is a crucial time, however anecdotal evidence shows that many more dogs survive than die if correct treatment is administered in good time.
It is hoped that a positive response can be seen within 4-6 hours of starting treatment (depending on the disease), but in a serious, life threatening situation, the first 2-7-14 days can be a very worrying time. Assuming the dog has stabilised he will quickly feel much better, and if he is in hospital may be allowed home within a week.
When he comes home he will probably have a 'goody bag' full of drugs. He will be on a high dose of steroid, usually prednisolone, and he may also be on another immunosuppressive drug, such as Azathioprine. Your dog will be weaned off in a controlled manner according to his wellness and clinical observations.
Note: High doses of steroids must not be stopped abruptly. Your dog could go into an adrenal crisis if the medication is withdrawn too quickly.
In addition to immunosuppressive drugs he should have something to protect his stomach from excess acid. The last thing your dog needs when he is feeling poorly is a bleeding stomach ulcer caused by the drugs. Sometimes, Antepsin is given to coat and protect the stomach (but this must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed. Another gastroprotectant used is Omeprazole. To minimise irritation to the stomach it is usual for the daily dose of steroid to be split into two doses and given with food, one dose in the morning with breakfast and the other dose with his evening meal. I have known several dogs, who did not receive a gastroprotectant as a part of their treatment regime, and went on to develop anaemia. This is not autoimmune haemolytic anaemia but iron deficiency anaemia caused by bleeding stomach ulcers. Using a gastroprotectant is a good preventative measure. When the steroids have been significantly reduced to a low dose, a gastroprotectant may not be necessary.
Excess acid, produced because of the drugs, may make a dog prone to developing pancreatitis. A dog with pancreatitis will appear in pain and his back may be arched as if he can't straighten up. He may be lethargic, seem bloated and have a tender abdomen. Dogs usually go off food and water, may vomit and look depressed. If you suspect that your dog has pancreatitis, don't try to feed him because it will make the condition worse. Take him to the vet as soon as possible as he may require treatment or need to go on an intravenous drip to stop him dehydrating. Again, the risk of pancreatitis should be minimal once the dog is on a lower dose of steroids. A low fat diet is best when your dog is on high dose steroids or prone to pancreatitis.
As your dog's immune system is being significantly suppressed, he will be more likely to pick up infections, and will not have the ability to fight against them. As a precaution a broad spectrum antibiotic is often prescribed. Also it is sensible not to exercise him in areas where he is more likely to encounter infections, for example, a park or a popular dog walking area.
Whilst your dog is on high dose steroids he will want to eat and drink excessively. However, this also means that he will want to urinate more and this can sometimes cause temporary incontinence. You may have to get up to let him out during the night and if you leave the garden door open during the day, it may save some mopping up! He cannot help it and won't like it either, so don't be too hard on him, it's only temporary. You will notice as he is weaned off the drugs the unwanted side effects will subside and he should return to normal habits and behaviour. Urinary tract infections and/or bacterial skin pustules are not uncommon when a dog's immune system is suppressed, and this is often the reason for a dog to be off colour during this time. Note: Always consider a urine infection if your dog seems under par. A course of antibiotics will usually sort this out quickly.
Depending on what autoimmune disease your dog has, he will probably need to have regular blood tests. Biochemical blood tests will also keep an eye on other body functions, such as those of the liver and kidneys, which is important at this stage.
Assuming good progress is being made, the clinical signs of his illness are diminishing and positive signs of improvement are apparent, your vet will want to start weaning him down from the high doses of steroid. This process can take 3-6 months or more, and usually begins any time after 10 - 28 days from the start of treatment, depending on the results of his blood tests and his clinical signs.
Relapses are not uncommon, especially in diseases that are difficult to control, for example SLE. A relapse may mean that initially, your dog needed to be on a higher dose of immunosuppressive drugs for a longer period of time, or your dog may have been weaned off a little too quickly and then the dose withdrawn too soon.
If a relapse occurs he will probably show similar clinical signs to his initial crisis. He will have to go back on an immunosuppressive dose of prednisolone, but it may not have to be quite as high as before. A combination drug may need to be added at this stage. The weaning process will then have to start all over again. Returning to an immunosuppressive dose will mean that he has to go back on a gastroprotectant.
Side Effects of the Drugs – Iatrogenic Cushing's Syndrome
Iatrogenic Cushing's syndrome is a side effect of high dose steroids and is caused by too much corticosteroid in the body. To a lesser extent, the immediate side effects observed when the dog initially goes on steroids eg., drinking, eating and urinating excessively is a mild example of Cushing's syndrome. Personally I like to see dogs responding to high doses of prednisolone in this way, as it means that they are responding to the drugs as they should.
Usually, Cushing's syndrome only becomes a real problem when exceptionally high doses, or prolonged high doses of steroids are administered, maybe due to a relapse, or in some cases where the vet is inexperienced in reducing steroid doses and keeps the dog on a high dose for longer than necessary; or when the dog is not responding to treatment and higher doses are necessary to control the disease. This is where the cytotoxic drug Azathioprine, and other more recently used, immunosuppressive drugs are very useful.
All drugs carry side effects and Azathioprine is no exception, but it does not carry the same side effects as prednisolone, therefore by using this drug in combination with prednisolone it reduces the risk of iatrogenic Cushing's syndrome. As Azathioprine takes at least 10 days to take effect, starting the 'combination' therapy at the beginning of treatment may enable the prednisolone to be lowered within the 10-28 day band and still maintain a good level of immunosuppression. If your dog is not responding to treatment then your vet may consider changing his treatment to other immunosuppressive drugs.
How Can I Tell if My Dog Develops Iatrogenic Cushing's Syndrome?
Iatrogenic means 'drug induced'. Clinical signs of Iatrogenic Cushing's syndrome are the same as primary Cushing's syndrome but can present with acute clinical signs. It reflects the level of corticosteroid in the body.
The most notable side effects are, heavy panting, some hair loss, and an increase in drinking and urinating, excessive pigmentation. This is something everyone seems to be aware of and accepts as normal when a dog is on high dose steroids. Very often the dog will be weaned down to a low dose before any major problems arise.
Acute Cushing's syndrome due to overdosing of corticoid steroids can be very serious. Blood results will reflect this, especially the liver enzymes which may be extremely high. Red blood cells and blood platelets may also be high and blood clotting may be a risk.
So when should you alert your vet to suspected, unacceptable level of corticosteroid? The owner should take note when other clinical signs occur, such as: Depression, anorexia, muscle wasting and extreme weakness, continuous panting, lethargy - unwillingness to exercise, skin lesions and thinning of the skin, excessive hair loss, pot-bellied appearance and sagging back, behavioural changes (aggression).
If your dog is showing these signs it will probably mean that the dose of steroids needs to be lowered. It is important that it is not confused with a relapse of the dog's condition or an infection. The dilemma is that steroids must not be withdrawn too quickly otherwise the dog may go into an adrenal insufficiency crisis. If the clinical signs of iatrogenic Cushing's syndrome is intolerable, it is hoped that the high dose of steroids that he has been on will have already done their job and that his autoimmune disease will be stable. As long as the steroids are lowered in a controlled manner and in time, all the symptoms of Cushing's will subside and your dog will return to normal, but extreme signs must not be ignored.
The Importance of Correct Treatment and Dosage
Iatrogenic Cushing's syndrome may also occur if the vet has initially prescribed a dose too high for the size of dog being treated. For example: I received an email from the owner of an Irish Setter, with AIHA. The dog was prescribed 200mg of prednisolone each day. I called the owner, only to hear that the dog had to be put to sleep that day. I was not surprised. The poor dog was on nearly twice the highest, recommended dose of prednisolone. She was 9 years old and had never had a day's illness in her life. What a terrible shock for the owners and what a lot of unnecessary suffering. I know what it feels like because I too, have lost a dog due to prescribed overdosing of prednisolone. The feelings of responsibility are enormous.
In contrast, some dogs are not treated with enough prednisolone. Here's another story:
A greyhound diagnosed with immune mediated thrombocytopenia (IMTP). Her vet gave her an initial shot of dexamethasone (a steroid which is 6 times stronger in terms of glucocorticoid activity than prednisolone). Some vets choose to give a shot of 'Dex' as an initial therapy in autoimmune disease, especially if the patient is acutely ill. Its effects can sometimes be seen within 6 hours and lasts for 36-72 hours.
The vet did really well and a marked improvement in her clinical signs was seen. It is usual, 24 to 48 hours after the shot of Dexamethasone for the treatment to change to an immunosuppressive dose of prednisolone tablets and for the owner to continue treatment in the usual way. However, the vet only prescribed 5mg of prednisolone a day. The owner said they were very concerned that after a few days of improvement, she seemed to be very poorly again. The vet couldn't understand why she was not continuing to improve. He gave her another shot of Dexamethasone and the same improvement was seen. I suggested to the owner that she either spoke to her vet about putting her dog on an immunosuppressive dose of prednisolone or change her vet. They saw another vet in the practice, who was more experienced in treating autoimmune disease, and the dog was put on the correct, immunosuppressive dose of prednisolone and the treatment was successful.
These case histories demonstrate how important it is to treat promptly and correctly.
Reducing the Tablets
When significant improvement in the dog's condition is seen, usually between 10-28 days, the initial steroid dose is usually reduced by 25%. The dose is generally given for another 10 - 28 days and depending on the dog's progress and clinical signs the dose is significantly reduced once more for a further 10-28 days; and again in another 10-28 days. Anecdotal evidence has shown that if at this stage the dose is lowered more slowly, or reduced to an every other day dose over a period of months rather than weeks, relapse are less likely to occur. It is always tempting to get your dog off steroids as soon as possible, but when treating autoimmune disease, as long as the dog is on a low, every other day dose then taking the last stage slowly seems to work best, depending, of course, on the severity of the disease and allowing for the difference in individual response - no two dogs reactions are exactly the same. With some autoimmune diseases such as SLE, the dog is likely to be on steroids for the rest of his life. Usually an every other day dose can be achieved, but you risk a relapse if you take the dose too low. Below is the best example of a reducing immunosuppressive protocol I have come across. It is an excellent guide and can be adjusted to the individual.
.
How Do I Know if My Dog Will Relapse?
Until you have attempted to wean your dog off of the tablets for the first time you will not know if he is likely to relapse or not. Sometimes during the weaning off process, before you even get down to an every other day dose, he may relapse. If this happens then the drug dosage has to be raised, probably up to the last dose before the relapse (maybe a little higher, depending on the severity of the relapse) and then start the weaning process again. If this happens again, then you and your vet may have to settle for keeping him on a low maintenance dose to achieve a good quality of life. A low, every other day maintenance dose of prednisolone is preferred to enable the dog's liver to rest in between doses. There are many autoimmune diseases that carry a good, drug free prognosis. The more common, serious autoimmune diseases that may not need long term steroid therapy are: primary immune-mediated polyarthritis, autoimmune haemolytic anaemia and thrombocytopenia. However, as previously stated, all dogs are different and it very much depends on the individual dog, the severity of the disease, the experience of the vet and the vigilance and compliance of its owner.
If a relapse occurs whilst the dog is still being treated then true remission has not been achieved. If the dog has achieved remission and has enjoyed a period without drugs or is on EOD maintenance drugs, when a relapse occurs or he develops another autoimmune disease, he has encountered a 'trigger factor' which has induced this change.
Quote from: tjh46633 on August 17, 2020, 09:04:42 PM
Thank you again! This is very helpful information.
His prescribed steroid protocol is this: (He weighs 20kg and the tablet is 20mg)
-Give 2 tablets by mouth every 12 hours for 1 week, (this was decreased to 5 days after adverse reaction of bloody vomit)
-the give 1 tablet by mouth every 12 hours for 6 weeks, (we are on week 5 of this)
-then give 1 tablet by mouth every 24 hours for 6 weeks,
-then give 1/2 tablet by mouth every 24 hours for 6 weeks,
-then give 1/2 tablet by mouth every 48 hours for 6 weeks, then discontinue
Having a plan - or a protocol - is one thing, but when a dog is on prolonged, high doses of preds the situation has to be
assessed every day, and if the obvious side effects are a problem, and increasing, then the protocol must be changed no matter if it is a few days after the reduction of meds or a few weeks. The protocol is only a rough guide to treatment and all dogs will respond differently to these high doses some, especially large dogs, will not cope too well; smaller dogs, and sometimes puppies, will cope better with prolonged, high doses because their metabolism is quicker.
The preds have done the major part of their job and now it is about reducing the dose and achieving a balance between the drugs and their adverse effects which are numerous; and successful weaning off and achieving remission. Being on high doses for longer periods doesn't necessarily mean it is a better protocol with a better outcome.
Jo
Prednisolone: "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight." Plumb's Veterinary Drug Handbook Eight Edition.