CIMDA

Hi

I have a four year old Whippet called Merlin and he has IMTP. He's at the start of his story with this worrying condition and I hope this site will help us feel less worried and confused about it all. I will post more about Merlin later :)

I treated all four of my dogs with Advocate Spot On treatment a few weeks ago and within 48 hrs bruises had appeared all over Merlin's body. He had bleeding gums and when we looked at him swellings began appearing and disappearing and each time they did,a bruise would appear in place of the swelling. I took Merlin to the Vet's and blood was taken and merlin was given Vitamin K in case he had ingested poison( although we knew he hadn't).
The Vet said that no other treatment would be given until they knew what they were dealing with. That evening more bruises appeared almost before our eyes and thanks to advice from a lovely Vet friend I took Merlin to the emergency Vet. He was given intravenous steroids and a course of antibiotics and within a few hours his gums had stopped bleeding and no more swellings appeared.
To cut a long story short, Merlin has been very close to dying for three weeks and is still not out of the woods. He's had some terrible bleeding inside his eyes and is on 25mg Prednisolone a day.
During the last three days he has had no visible bleeds and he currently doesn't have a single bruise. However, his platelet count has gone from 1 to 13 to zero to 30 then back to 18. I have no idea what this all means and can only take comfort from the lack of current bruises.

Merlin is having a full blood count on Friday to see what is going on. I have looked at the blood results which were emailed to me last week but they show not just platelet problems, they seem to show high basophils at one point and high neutrophils and a few other worrying signs and something called moderate polychromasia which is something to do with new red blood cells I think.

This whole experience has been extremely stressful and whilst we've been calm and as normal as possible for Merlin, it has taken its toll on us a bit. I do not know what the future holds for Merlin and have everything crossed that his platelet count is going to stabilise and continue to increase now.

Five weeks ago I could not have imagined the course that merlin's life has taken and it is very shocking that this all happened very quickly ie in 48 hrs. At one stage we were offered a plasma transfusion but were told that at best it would buy him a few hours so we decided that the stress of putting him through it would be worse for him than any benefit gained. We have kept him as quiet and relaxed as possible and tried to protect him from being bumped and bashed about. Very difficult with three other dogs in the house!I cannot prove that the Advocate treatment caused this to happen but I suspect that it was probably Merlin's trigger.

To anyone else going through this at the moment, you have my deepest sympathy,it's very hard to explain just how worrying it is and in Merlin's case for three weeks I dreaded coming home from work in case I found him dead :-[

What medication is Merlin on? If he is given the correct medication and dosage then the platelets should start to increase. Here is a good medicine protocol:

"Immunosuppressive Protocols for Oral Prednisolone in the Dog.
Ref: Clinical Immunology of the Dog & Cat by Michael J Day  – 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/q12hrs

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h          10-28 days
0.25mg/kg/q24h          10-28 days
0.25-0.5mg/kg/ Every other day      at least 21 days
0.25-0.5 mg/kg/ Every third day       at least 21 days

Azathioprine (a cytotoxic drug) can be used in combination with prednisolone at 2mg/kg/24 or 48 hrs and dose gradually reduced, when remission is achieved, over a period of months.
Clinical response to Azathioprine may take up to 6 weeks. (Plumb's Veterinary Drug Handbook)

Don't forget the gastroprotectant!"


You can read more about IMTP here: http://cimda.co.uk/smf/index.php/topic,12.0.html

Thank you.

Merlin is on 12.5mg of Prednisolone every 12 hrs and from tomorrow they have reduced it to 10mg every 12 hrs. Hopefully the blood test on Friday will show a much improved platelet count.

I would err on the side of caution and NOT reduce the medication until you see on Friday whether the platelets are actually increasing. If he is not suffering from the medication then waiting a day or so to see if it should be reduced seems to me prudent. But check with your vet anyway.

The vet just rang me and she said she is concerned about the platelet drop and is ringing a medic at Idexx to see if she can find out what may be going wrong etc and to adjust his treatment if necessary. Feeling rather thankful that she is doing so and hopefully we will have a clearer picture later today. Clinical signs are good,he looks fabulous and looks and behaves like my normal sparkly little boy. :D

Oh I did not realize you added more information to your original post - have only just seen it!

Do you know what Merlin's HCT (PCV) level was? If it is low he could have AIHA as well. This is called Evan's Syndrome. See here: http://cimda.co.uk/smf/index.php/topic,13.0.html

Do not forget you could add something like Azathioprine. Also Vincristine can help the platelets rise.

Hi
sorry i was at work when I originally posted and I updated my first post when i got home.

Haematocrit has stayed between 0.459 and 0.510 when his platelet count was 1 and 13 and zero and 30 but i don't have the lab report for his latest test but this was just a platelet count so I guess it won't tell me anything else.


When his platelets were 30 (ten days ago), his monocytes were high,WBC high,MCH and MCV high and reticulocytes were high. But I have no idea what any of this means. Waiting for the Vet to call is absolute torture.

Hi and welcome

I hope you get better news from today's blood test.

High white blood cells are seen in immune mediated disease, inflammation and infection but they can also be raised as a result of steroid use, especially high monocytes.  So I wouldn't worry about that.

MCH and MCV and raised reticulocytes all reflect level of anaemia.  His haematocrit (HCT) result is within normal limits which is unusual when the reticulocytes are high because the level of reticulocytes reflect the level of anaemia - and if you believe the result he doesn't appear to be anaemic!  I can only imagine that the bleeds have lowered his HCT but his bone marrow is responding and therefore keeping the HCT within normal levels.  The other possibility is he may be dehydrated and this can give a false, higher reading of HCT.

I'm sure you will find out more today.  Good luck.

Jo

Thank you. Strange that you mention dehydration because ten days ago,around the time of that blood test I noticed he wasn't drinking water as normal. He's never drunk a lot but I realised he was drinking nothing so I added water to his dinner to help him. So you're probably right about it being down to dehydration.

Hello Merlin's Mum
I have only just updated myself with the new messages and have read your messages and the first thing I must say to you is to try and remain positive.  These are easy words when your dog is so poorly but believe me you are not alone.   I too have a dog that has IMTP and at the start, I thought I was unique (or at least dealing with something that was rare and hopeless).  Many of the side effects you are experiencing, I have had the same with Harley...it is often part of the course unfortunately and I have to say uncertainty is the worse part..i.e. not knowing what is causing it, what has caused it, what effect this is having on our dogs etc....

When Harley was first diagnosed, we too had abnormal RBC and WBC counts but fortunately this was rectified after a short while.   We have had the odd occasion when his WBC's were elevated but antibiotics resolved this.  They are much more prone to infections when they are on Immune-suppressant drugs, as you would expect.
I wouldn't know if your flea treatment was connected to the onset of Merlin's problems, as I don't use these type of treatments but I wonder, did you use the treatment because you had seen a tick on Merlin?   The reason I ask is that just a few weeks before Harley's diagnosis, he had a horrible Tick-bite localised infection and whilst the tests came back from IDEXX as being negative for 'known' Tick-born disease, I add the 'known' as I still remain unconvinced that there wasn't a connection between the two.
We didn't see the more common 'bruising' on his body but we did have tiny Hemorrhages in his ear flap and bleeding gums - however, he had been chewing on a Nylabone and sore gums wasn't uncommon......I had no idea at all he was so poorly.   Looking back though, I remember that he was such a poor eater and was underweight for his age.   I now realise that this can be one of the symptoms.

At the start, Harley's platelets were terribly erratic.   They started at 30 but we waited for the blood results at the vets and came home with an immediate Immune-suppressive dose
of Preds.  Harley weighed around 30kg and we were on 30mg twice daily (60mg a day).    Unfortunately, going back, I now realise that we lowered the dose too prematurely probably.

We are currently on our third attempt, we have three times returned to Immune-Suppressant doses of Steroids.   Supplementary drugs haven't always helped i.e.Atopica for a while...this resulted in an all-time low in Harley's blood count (20) but in fairness, I have heard of many that have had really good results from this.   Azathioprine worked much better and we are still on 50mg EOD whilst lowering the steroids very very gradually.  No two dogs are the same and each may respond differently to any one drug.   Steroids seem to be the one thing that he is responsive with at the moment and I personally think we may have to face remaining on them for life - though hopefully, we will fine-tune to try and keep them as low as we can.
One thing, in our case, I am insisting on at the moment and that is to resist lowering the Preds at all until we have a very positive increase in his platelets and even so, I insist that we stay on the last dose of Preds for at least one month before lowering them.   Time and time again, we have experienced an increase in his platelets but were soon to realise that it was a temporary bleep and they soon dropped.   I feel more comfortable doing things this way - even though my Vet thinks we could afford to drop a little more than my .5mg at a time.
Also, we are trialing another drug that hasn't commonly been used for IMTP.....too early to know if they are effective so won't comment on this.

I do hope you get a positive result soon, on what is really causing the problem and confirmation if it is IMTP or IMHA (or both).

I will try and keep an eye on the messages, as if I can reassure you on purely things like side-effects that you may see.....knowing that someone else has experienced the same can only comfort I'm sure.  You may well see insatiable appetite and thirst and as you would expect, visits to the loo are numerous (matchsticks keeping our eyes open from disturbed nights' sleep...small price to pay though), muscle wastage was a big problem in our case....risks of infection,  skin sores and loss of coat sometimes.   Hopefully, you may not get any of these or maybe just one or two but most are reversible as soon as the meds can be safely lowered.   The big rule is....don't rush it.   Let the drugs take time, providing of course that Merlin is o.k.on them obviously.

I do hope all goes well for Merlin.

Thank you for your kind reply.

Just back from the Vets and according to Idexx the fluctuating platelet count is not ideal. Our vet wanted to start him on Cyclosporine today but I have asked her to wait until we see the platelet count tomorrow. If his count is still low then we will start him on cyclosporine but I want to wait because I don't want to stuff him full of drugs IF this fluctuation was a blip. Again today there is no bleeding or swelling after blood was taken. Although he didn't bleed or swell last time blood was taken, he still had small capillary bleeds in his ears and on his legs. For five days he has been bleed free with no visible bruising at all.
He is still on the 12.5mg Pred every 12 hours and we are not dropping his dose for the moment until we know what his platelets are.

The Vet said whilst they think he has Primary IMTP they would need to do ultrasounds etc to see if he had a tumour if his count is still low but he obviously can't have anything done unless his count is brought much higher. Our options are wait until tomorrow and if the count is much higher we stay on Pred  dose another week and then begin to drop. If the count is still low we add cyclosporine and if that works, then we know for sure it is Primary IMTP. If not, the thought of tumours etc doesn't bear thinking about.
We are worried that he has lost some weight.In four weeks he has dropped from 12 Kg to 11.25kg. I am giving him some extra food to see if he builds up a bit but he is a spindly whippet anyway but the weight loss is a concern.

Sadly we have been here before with Immune problems and I had a Whippet pup called Felix who had a severe anal stricture from birth and  inflammatory bowel problems and developed perianal fistula's and he was on Cyclosporine but he was put to sleep at seven months ( when Merlin was a year old) as the prognosis from the RVC was very poor. I also had  Beagle with epilepsy and liver disease who was put to sleep aged 6 years.The stress of the uncertainty is awful and I can't believe we're having to go through these worries yet again with another sweet little dog.

This was Merlin when his platelet count was zero.......you can see the bruises

(http://i10.photobucket.com/albums/a115/zookiheap/dogs/11034184_10204926879385077_8534664220995729332_n_zpsxra1brcq.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/dogs/11009984_10204905892780425_6707768794027064642_n_zpsltbesp9r.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/dogs/10360466_10204905893460442_7064273482023084757_n_zpsyp6au8xj.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/dogs/11050219_10204905894900478_6492006086782872834_n_zps7l1jkhvx.jpg)

This is him on his fourth Birthday last Saturday.....
(http://i10.photobucket.com/albums/a115/zookiheap/dogs/11205977_10204998974107400_4046364456896703441_n_zps6tf9tr1h.jpg)

Oh I feel so for poor Merlin - he looks such a sweetie.


Hopefully it is primary - in most cases it is but if you have to have an ultrasound, I wouldn't think there would be a problem whatever hois platelets were.  I know thatit can be stress related but we are under Cambridge with Harley (jointly with my own Vet) and the first day we went to see them, his platelets though not very low, were around 100.
One thing they may say is that he has an enlarged liver but I was assured that this was to be expected and caused by the drugs.

I hope that you find the platelets much improved at the next blood test.      Presume you are giving Merlin something for his tummy (Gastro).   

Do Whippets tend to have a lower platelet count than some breeds?   I know that it does depend on the breed.
I wonder if the 'weight loss'  is through muscle wastage?   If you think how much muscle weighs and the degree the dog could lose whilst on Preds.   Just a thought!

So sad to read about Merlin's illness.

Such beautiful photos -  his face is similar to that of  my 11 year old whippet Jasper. Jasper  was diagnosed with IMHA 15 months ago  but he is now stabilised on a small dose of  pred every second day. 

Keep positive, read everything relevant on this web-site, and do not be afraid to tactfully inform your vets about  information you read on this web-site which they seem  not to have taken into account.
For example I have not had Jasper vaccinated since he became ill after reading here that it might  trigger a relapse and I bought an over-the counter gut protectant (Zantac) when my vet did not prescribe one.

It is important to mitigate  the  side effects of medication.  While on high doses  of medication Jasper needed to drink more than normal so I left multiple bowls of water  around the house so he could stagger to them when very feeble due to muscle wastage ( another  side effect of the medication).  I fed Jasper boiled chicken with rice  which helped him gain weight and  muscle mass.   The side effects of medication made it seem that Jasper was getting worse instead of better  but I learned from here  that it is unwise to  rush into reducing the medication too early.

Co-incidentally, two days ago I noticed a small  bruise/inflammation  on Jasper's eyelid  similar to those on your photos of Merlin and would have taken him to the vet yesterday if it had seemed worse.  It is better today but after  reading that IMTP and IMHA can occur together I will monitor it closely and get a full blood test done if I notice the any other bruises/inflammation patches.

I should have written such a beautiful dog - not  beautiful photos. Some of your photos are very graphic  and not at all beautiful  - but it is very  useful to know what the symptoms of this disease look like.   Especially as  I recently noticed  a small similar bruise on Jasper. On breeds with thick fur would not be possible to see these symptoms so hopefully you have caught the disease in its early stages. 

Thank you. Sorry I often forget that my pictures might be too graphic. I'm rather practical and not at all squeamish.I worked at my Vet surgery for 3 years and witnessed all manner of things and it has helped me to deal with all manner of things which might put a petson off. I thought if I posted them they would help people to recognise the condition. Under his coloured fur he had dozens more.
He has a small bruise where blood was taken last night so my hopes of a higher platelet count seem futile. I suspect he'll go on cyclosporine tomorrow. Does anyone know if they can be weaned off cyclosporine like they can steroids or will it be for life?

Hi

Merlin is so beautiful.  Thank you for posting the photos.  It is useful to others to have a record of the bruising that can happen when a dog has IMTP.  You have had your share of terrible bad luck.

Have you asked your vet why they are not considering increasing the pred dose before introducing cyclosporin? Smaller dogs can tolerate much higher doses of prednisolone  (and for longer periods) than large dogs.  Merlin is light in weight and also, being a Whippet,  is likely to have a faster metabolism than other breeds, so it is quite logical that an increase in preds should be considered to allow for breed specific differences and his size. He might not be on a high enough dose to fully suppress the immune system.

The larger the dog (or other species)  the less they can tolerate high doses of prednisolone.  An immunosuppressive dose of steroids for a human would be much less per kg of body weight than  a dog, and a dog much less than a cat etc.., The smaller the species the larger the dose of steroids and this is due to the rate of metabolism.   Puppies often have to have higher doses of steroids for this reason.

Cyclosporin (and Azathioprine) is an immunosuppressive drug that is often used alongside prednisolone to produce a greater level of immunosuppression without increasing the steroid dose.  However, this will not rapidly prove if it is an immune mediated disease or not because it takes some weeks after starting cyclosporin before significant effects are seen, so for the next few weeks any improvement in platelet numbers will be due to the effect of preds and not cyclosporin. With life threatening diseases you don't have the time to wait for other drugs to kick in.  I'm not suggesting a combination drug isn't introduced at this stage but it won't have immediate effect. 

It is known that Whippets (and some other breeds) can be genetically predisposed to autoimmune disease, so given Merlin's age and his breed it is more likely this is IMTP than any other platelet disorder.  His favourable clinical signs fit idiopathic IMTP too.

Sighthounds, Cavalier King Charles Spaniels and Shiba Inus,  are known to have naturally lower platelet counts than some other breeds. This could mean that a lower platelet count in a whippet correlates to a higher one in a different  breed, and the low count of 18 is having greater effect in Merlin than it would have in a collie or a retriever, for example.  Perhaps this is why he wasn't bruising at 18 and he initially went right down to zero before it was picked up.

The Greyhound and whippet range in red blood cells is usually higher but the platelets are lower.  Please look at these links:

http://sloughi.tripod.com/preserving/haematologybiochemistry8sighthounds.html

http://www.recycledracers.org/FAQ/greyhound-blood-values.html

http://www.2ndchance.info/dxme-Platelets.htm

I hope you get better results today.

Jo

Hi thank you. He is currently on 25mg per day split into 12.5 every 12hrs. I'm not really sure what dose it can go up to as I have read conflicting things. He now weighs 11.25kg as his weight has dropped a bit.

I would follow Jo's advice, as cyclosporine takes 2 to 4 weeks before it really starts to work. It can be great for some dogs (like mine), but others have difficulty on it. You definitely want him stabilized before starting on it... and yes, after 4 weeks on it you would be able to slowly start decreasing the pred.

Hi |

Immunosuppressive dose prednisolone is 1-2 mg/kg/12 hours. (Clinical Immunology of The Dog and Cat by Michael J Day)  Treatment  has to be started at least, on the lowest immunosuppressive dose, but there is room for adjusting the dose to the individual and how much progress is or isn't being made.

Jo

I am the happiest owner in the world this morning.Merlin's platelet count was 167 on Friday. As of Monday we are doing a slow reduction in steroids and repeating platelet counts every seven to ten days. The Vet sounded so pleased on the phone. I am so glad I refused to put him on Cyclosporine on Friday and wanted to wait for this blood result. Owners know their dog best and my gut feeling was that his count was much higher than 18. I realise he could slip backwards and we need to take care but after a month of stress, this is just wonderful. I've had a good cry this morning, I'm such a sap but if you knew thislittle spindly boy like I do,you'd have had a little sniffle too. Thank you so much for all the help and advice so far. I'm sure we'll need you again and I'm very thankful for this forum. X

That's brilliant news!!!!   You have to trust your instinct.  I'm not surprised you shed some tears.

I am a bit concerned they are lowering the preds so soon after his platelet count has just reached normal level. 

If the drug regime is correct the count should increase and not go back down.

A happy day for sure.

Jo

Thanks for sharing the photos, I think it's very useful for other folk to see, even if they are graphic, they are brilliant for reference.

I agree I wouldn't be reducing the meds just yet, he needs to stabilise first.  But I'm sure your vet must have thought it through and hopefully they have experience with treating IMTP.

I take it you won't be flea treating again  :-\

I won't be flea treating,or worming and I am going to look at antibody testing rather than automatically vaccinating my other dogs as well. Obviously at the moment Merlin can't be vaccinated whatever.
I am a bit concerned about reducing the steroids but keeping a close eye on his bloods should guide us too.
He's been on 25mg for 25 days so far but the first ten days it was once a day because a different vet gave us wrong instructions. Since having it 12hrly his count has improved. He's having blood taken next Friday morning. There is nothing to stop me keeping him on current dose until Friday though, after all I administer the pills!

Hi

I was told by a friend whose dog was put on Atopica (Cyclo) for a different A.I.disease (and which, worked really well for her) that their advantage over steroids was that there wasn't a winding down of them and didn't have the side-effects that steroids give.  They may have their own side-effects however.
When we used them and found them not to work, my Vet still knocked them down over a limited period but I think that was to give them a bit more time than anything else.

Gwyneth

Sorry I think my remarks about cyclosporin/Atopica came a bit late, as I didn't notice the messages had gone on to further pages....

I am thrilled though to hear that you are getting a more positive response to the steroids......such good news.

To me, it does seem early to consider a drop in the dose though, as although the result was good - I would think that they are looking for them to rise further.
It's so hard when you read about other cases, as dogs are all different and they all cope with drugs differently.  Perhaps your Vet feels that Merlin needs come down lower for some reason but if he is only showing the expected side effects and otherwise he is fine, It would be interesting to learn  why they don't keep him on the dose a little longer to ensure he is at least holding at that level or better, rising?  Only my thoughts.....not advice I promise.

Thank you,advice is always welcome. I am actually keeping him on the same dose until Wednesday, which gives him a few more days. I'll confess to the Vet on Friday and get more steroids and ask that we have him on 20mg per day for at least three weeks and just be guided by the bloods. On Wednesday he will have had 28 days on 25mg.
And thank you again,thoughts or advice are what gets us through these worrying times and without you guys and forums like this, I would have been totally at the mercy of the Vet's and not had the courage to question and make decisions for mydog myself.

It's always good to ask more and more questions, even if you feel you're annoying the vet! the most important thing is Merlin !

Just thought I'd update this.

Just had a call from one of our lovely Vet's.......Merlin's platelet count for yesterday was 291.....how fabulous is that! If all is well in another week I think we will be reducing his steroids a touch. That will be a good thing because the steroids are changing him in a way I do not like.

They are a necessary evil at the moment unfortunately.
None of us like the way the steroids affect our dogs, but for so many they have saved their lives.
It's brilliant his platelets have gone up again.

Thank you. Yes his platelets have had a good climb. He has been on 10mg pred every 12hrs for the past four days and they still climbed which I'm hoping is positive. He will be on 10mg until next weekend,at which point it will be reviewed and depending upon next week's blood count,they may be dropped but I'm not sure by how much. At a guess I expect them to say drop by 5mg.

Perhaps they can compromise and go to 7.5mg twice a day for a week or something? it's a great result.

Quote from: Penel CIMDA moderator on May 16, 2015, 08:00:19 PM
Perhaps they can compromise and go to 7.5mg twice a day for a week or something? it's a great result.

Thanks, yes I would like them to drop to 7.5 twice a day. He was on 12.5, now 10 and he will have been on 10mg twice a day for 14 days by the time we get next weekends result. In some ways I wamt his dose down or gone asap because I want my sweet little dog back but on the other hand I worry like mad about his platelets dropping again.

Hi,
I am coming into this very late and can't offer any advice on this disease, but just wanted to say what a beautiful boy you have and how hapoy I am for you, that Merlin has turned the corner. I know from some experience of other AI diseases, that patience is needed, but then that is so hard when it involves such precious souls as those we have in our care.

Big hugs from me and mine

Pam

Am quite disappointed to report that Merlin's platelets have dropped back to 161. He has been on 10mg pred for 14 days now. Am waiting for the Vet to call me back but I doubt we'll be able to reduce his steroids at this point as the last reading was 291. Such a worry.

The Vet just called and said because the platelets are still in the normal range and he's in no danger she wants me to drop his steroids to 7.5mg twice a day and retest bloods next Monday. If they've dropped again,she wants us to start him on Cyclosporine.

Hi

How is Merlin coping with the side effects of the steroids?

A drop of 130 is significant and I don't understand why the vet would think it was OK to lower the steroids.  He has only been on this dose for 14 days and considering how long it took his platelets to rise initially, why are they in such a hurry to reduce the preds? I can understand lowering the dose and introducing another drug if Merlin was reacting badly to the steroids. 

I think they should seek advice from a specialist.

Jo

I'm really worried now. I would have liked to give him another week on 10mg twice a day and rechecked his platelets before reducing the dose. Do you think it would be worth me going into the practice tomorrow and saying so? My instincts were right previously when I wanted to wait for platelet count when the vet wanted me to put him on cyclosporine.
Apart from hunger,thirst and a bit of muscle wastage he has no steroid side effects.

Right, I just rang the surgery and told them I want to keep him on the same dose for another week until we've had another platelet count and make a decision from there. Going to collect more steroids tomorrow.

If he is coping with the steroids I think it would be safer to not reduce until after he has had another blood test. I think it would be best to reduce slowly as well when the platelets are okay.

I also think I would be taking him for another blood test before another week has passed just to make sure his platelets are not reducing even more.

Well I have arranged not to drop the steroids until after next bloods on Monday but Vets said not to test this Friday which I was originally going to do. They want to test next Monday. We've done weekly tests from the outset so I'm not entirely uncomfortable with continuing with the same. Hopefully by keeping him on 10mg they won't drop further but will remain as they are. I will monitor him closely and take him to the Vets straight away if anything changes.

Hello Merlin's Mum,

I am so sorry to hear the news about Merlin's platelets but if he is anything like Harley, it was not unusual to see erratic behaviour - particularly I noted, at around the 10mg stage.    I have already said that as no two dogs are the same I am careful in adding that what I say was what we chose to do.....that was, when we got to the mid 200's,  we/I insisted on remaining on each current dose of preds for at least 4 weeks and in any event, until we saw an increase.    My Vet (and even Cambridge) wanted me to lower by 5mg when the platelets stayed in the "acceptable" range but to be honest I was too nervous, as this is our 3rd go and the previous attempts we had dropped the preds, I felt, too soon.
In our case, the 10mg stage was when we saw the downward hikes and so, I have insisted on dropping sometimes by only 0.5mg.
This last time, the blood count was only 30 lower and Vet and Cambridge said to lower again by 5mg but I haven't.   I have gone down to alternative days instead.   i.e. we were on 7.5mg and we went to alt. days of 7.00mg and 7.5mg.    If bloods went o.k., then and only then we dropped to the 7.00mg.
etc.
Of course, I am not a Vet and I don't fully understand how these things work but I am worried about rushing things at this stage and if it takes months of lowering to 5.00mg (if we ever get there!!) then so be it.  Particularly as there doesn't seem to be any adverse side-effects.
Obviously, if Merlin is having side-effects and the vet is concerned and feels he needs to be reduced quickly - then that is another matter.


Has your Vet used Azathioprine?   

Harley was unusual and didn't respond to Atopica.......so we really have very few alternatives now, which is why I am going this route.

I hope his platelets rise for you.....try not to worry, it isn't unusual to see these swings.......

Thank you for your reply. I am quite worried at the moment but have chosen to keep him on current dose until at least next weeks bloods. Then depending upon results I will decide if we reduce or if we stay on this dose another week. Obviously we want him on a very low dose or off steroids altogether eventually but I do feel the Vets are too obsessed with the negative side of steroids which is why they want to reduce his dose so soon. I will allow them to add Atopica if things don't improve but given its only five weeks since this all started I want to give him a chance to level out his platelets before we add anything else etc. I'm beginning to find it harder to trust my Vets as they seem to be giving me bum advice so am trying to trust my instincts. I know one lady Vet who will not be happy that I have decided not to lower the dose but he's my dog and I know him best and I do not think its in his interests to change anything at this point in time.

Hi

Just to let you know that the attitude etc., you are experiencing with your vets is not unusual.   Many vets in general practice really don't have the experience required to confidently stick to an immunosuppressive drug protocol and evaluate a situation correctly.  You need to find a vet who will work with you.  It is essential for Merlin,  and your sanity.

We are not vets but collectively there is a lot of experience on this forum, and experience is hugely valuable.  Experience gives confidence  to correctly treat unusual cases.

Trust your instinct.  I failed to trust mine once and it cost me my dog's life.

I hope Merlin's platelets have improved by his next blood test.

For what it's worth, I would rather give Azathioprine than cyclosporin.

Jo

Hi
Thank you. Please can you tell me anything relevant about Azathioprine in terms of dosage etc and out of interest why it might be preferrable to cyclosporin. I'm only asking as I want to push back at my Vets a bit and get the right treatment. Thefirst thing they will ask me is WHY? Thank you very much. This forum is keeping me sane and hopefully giving Merlin the best possible chance. :)

Quote from: Jo CIMDA on May 27, 2015, 11:07:20 AM


For what it's worth, I would rather give Azathioprine than cyclosporin.

I would too.  I'm slightly perturbed that vets seem to be heading straight for Cyclosporin these days, rather than trying Azathioprine first (with the pred).

Quote from: Penel CIMDA moderator on May 27, 2015, 10:04:19 PM

Quote from: Jo CIMDA on May 27, 2015, 11:07:20 AM


For what it's worth, I would rather give Azathioprine than cyclosporin.

I would too.  I'm slightly perturbed that vets seem to be heading straight for Cyclosporin these days, rather than trying Azathioprine first (with the pred).

Yes Penel,  I  wonder if it has anything to do with the cost?  Azathioprine is not licensed for animal use but it has been used very successfully for decades as an immunosuppressive.  Cyclosporin is licensed for canine use but only for atopic skin disease although they seem to use it more now for every AI disease. It is very expensive.   Some dogs can't tolerate Aza but in general it is tolerated very well, and because it has been used for decades its side effects are better documented.

Cyclosporin seems to be less well tolerated than Aza and although both drugs are cytotoxic (toxic to cells) I would rather Aza.

Here is an extract from my notes:

Azathioprine is usually tolerated well, but as with all drugs individual dogs can be affected in different ways.  Side effects can include reduced bone marrow production, but this is rarely a problem unless the dog is kept on this drug for a long time. In contrast to prednisolone which has a rapid effect on the immune system, azathioprine takes at least 10 days to have some effect and approximately 4-6 weeks to reach its full potential. 

Note:  Azathioprine and all other cytotoxic drugs should be handled with extreme care. Cytotoxic drugs should not be handled by pregnant women.  Rubber gloves should be worn and the tablets should never be split or broken.

Atopica  (cyclosporin) is licensed for treatment of atopic dermatitis in the dog but it's increasingly being used as an immunosuppressant in 'combination' treatment with prednisolone and azathioprine for systemic autoimmune disease, despite the drug sheet stating   'It is not recommended to use other immunosuppressive agents concomitantly'.  I have known many dogs on this triple combination treatment that have eventually become overwhelmed by the side effects of the drugs and the outcome has been poor.  It may be worth, initially, trying a more simple approach to treatment, using immunosuppressive doses of prednisolone, before embarking on a 'prescription overkill' that may prove to be a difficult,  and an unnecessarily heavy drug regime for the dog. Human research suggests that cyclosporin may also encourage abnormal cells to become cancerous and perhaps even grow more aggressively. Scientists are now looking for ways to block this tumour-promoting effect of cyclosporin. (Clinical Pharmacology Made Incredibly Easy by Lippincott, Williams & Wilkins)

It must be accepted that sometimes these 'heavy' drugs have to be used, especially if the dog is not responding to treatment; and sometimes an additional drug can make all the difference to the recovery of the dog. In these cases the side effects have to be accepted as a 'trade off', in fact the dog may tolerate it very well.  However, there may be no need to prescribe combination drugs when there is a good chance that using immunosuppressive doses of steroids, and following the correct drug regime, may be all that is required to bring the disease under control.  The severity of the disease has to be taken into consideration when deciding on which combination drug regime to use, but more isn't necessarily best, and introducing one combination drug at a time would limit the side effects for the dog.

Tip: If you are not sure about something, never be frightened to say "I can't afford it".  There may always be other equally good options offered.

Jo

Jo

Thanks very much this is very useful. Depending on platelet count on Monday I will be asking to put Merlin on Azathioprine alongside the Pred. From what I understand,we need to do a full blood count at four and eight weeks on the Aza to review its effects? What sort of dosage would I be needing for a 12kg dog? Thank you again. I like your TIP, that's something they can't really argue with ;D

Hi

The dose for Azathioprine is 2mg/kg/24hrs until remission achieved then 0.5-2mg/kg/48 hrs. BSAVA Small Animal Formulary, 6th Edition

If Merlin's platelet count hasn't dropped and is acceptable on Monday then you can leave him on pred only (whether it is reduced or not) or introduce Aza as a combination therapy.   

Having a full blood count is never a waste of money but liver enzymes will be raised regardless of whether Merlin is on a combination therapy or just preds.  Generally, bone marrow suppression doesn't usually cause output to drop below the lower level of normal and has little clinical effect. 

I wonder what their plan is if Merlin's platelet count has dropped significantly and they are of the opinion that his platelets are still being destroyed?  Bear in mind the Aza and cyclosporin doesn't kick in for at least 10 days and won't reach its full potential for several weeks, so this will not address the immediate problem.  Merlin's preds might have to be raised at least until the combination drug is having some effect.

Something else to consider is Melatonin.  DW's Harley has been on this for about 6 months now and it might be worth considering its use for Merlin.  Check out this link:

http://www.ncbi.nlm.nih.gov/pubmed/12424512

Jo

Thank you. I have no idea what their plan is but if his platelets have dropped I will suggest increasing pred back to 12.5mg twice a day and adding azathioprine. If they are reluctant I will insist. If they point blank refuse,which I doubt, I will find a Vet that will agree with the treatment.
Could Merlin stay on 10mg of pred twice a day for longer than 28 days? I know the protocol is 10 to 28 days but I'm thinking ahead.....a week from next Monday he will have had that dose 28 days. If his count is still good, I will consider reducing the pred and discuss whether or not to add another drug. This whole experience is new to me and was completely out of the blue. Its only because I read up about immune disease in whippets a couple of years ago( when I had a 7 month old whippet with perianal fistulas)that I had an idea of what was wrong with Merlin.
The whole drug regime thing is something I'm relying on you guys for because I don't think the Vet's really know much about treating this condition.

Hi

Merlin can stay on 10mg of pred for as long the disease dictates and his clinical signs allow.  The dose and duration is only a guide and the regime has to be tailored to the individual dog.  Relapses are not uncommon and the preds have to be raised to address the immediate crisis.  Introducing a combination drug is a good idea if the dog has to remain on a reasonably high dose of preds for longer than the ideal.

I am hopeful that Merlin's platelets will be good and the only decision will be whether to keep him on the current dose for a bit longer or to reduce the dose.  If he is coping well with the drugs then there may be value in keeping him on the same dose for a bit longer. 

Jo
 

Little update.....took Merlin for his blood test and Vet agreed with my request that if platelets have dropped we will add Azathioprine and if necessary,temporarily increase pred. If platelets are good, which is doubtful given how his neck swelled when blood was taken,then I agreed to reduce pred to 7.5mg twice a day.

The really disappointing thing today is that bloods were taken 4hrs ago and not thirty minutes ago,Merlin became lame,hopping round on 3 legs. He has a hole in a toe pad and something like a piece of glass has gone in and there is pus coming out. Its a small hole but nonetheless he could have shown some hint of it before I took him to the Vet but in true Merlin style he waited until now!
Ive cleaned and dressed his front foot and put magnesium sulphate paste on the wound to draw out any foreign body but he'll need antibiotics tomorrow. Hoping I don't have to take him back in and they'll let me have some when I talk to Vet about his bloods.
Right now Merlin looks like a wounded little old man,not the beautiful four year old boy he's meant to be.

I am sorry to hear Merlin has hurt his foot also. Maybe bathing in salt water will help. I know many years ago, when my standard poodle cut her pad underneath, the only rhing that eventually made it heal was bathing it in salt water? One of my vets always suggests this if any similar problems have arisen.

I hope you bet better news very soon.

Pam

It sounds like a good plan for Merlin.  I hope his foot gets better soon, but steroids inhibit healing so antibiotics will be a good idea.

Jo

In five hours Merlin has gone from having a normal size paw to this.....
(http://i10.photobucket.com/albums/a115/zookiheap/10012442_10205226877084832_199778313523556424_n_zps3r1ypacz.jpg)

He has an appointment for 6.50pm but I have rung the vets and they will see him in just over an hour as his foot is very very red underneath.

Would this degree of swelling/reaction be expected when his immune system is suppressed?

I am not sure whether that is due to his suppressed immune system. Could there still be some foreign body inside? Has he had the magnesium sulphate paste before or could he be allergic to it? Could you bathe his paw again in just water to see how it helps and not put any medication on it?

He's had the paste before. We're at the Vet's and they've gassed him down to examine and clean his paw.

I hope Merlin gets on well at the vet.  Is the redness bleeding under the skin?  I wonder if he has some inflammation of the blood vessels, such as vasculitis? One thing in favour of it being a foreign body is that only one foot is swollen.  If it were an IM disease I would have thought both feet would be swollen.   Poor boy!

Jo

X ray shows no foreign body but huge amounts of pus drained from toe. There was a clearly visible hole in his pad so definitely injury. He's had painkiller and Convenia injection. I have to take him back tomorrow to re-examine and get course of antibiotics.
The toe with the hole is so swollen it is close to bursting and the skin on the underside was very thin and angry looking. I can't believe how bad it got in five hours.
Still no platelet count back yet but hopefully tomorrow we will know. I really hope his paw looks better tomorrow. He is sporting a cheery blue dressing but remains somewhat underwhelmed by it all.

At least you know what you are dealing with now.  When all the nasty stuff is out he will be feeling a lot better - and so will you I expect.

Jo

 Hope that once the antibiotics kick in your beautiful boy will be feeling much better and soon able  run around as usual with your other dogs. 

Hi

I need advice again please. Took Merlin back to vets and they have re-dressed his foot(which has shrunk a bit now,still swollen but not like yesterday although the toe with the small hole is still huge)and given him 3 days worth of antibiotics.

The bloods were in and the platelets are 150 so a drop of 10 and he is still on 10mg pred twice a day.

The vet didn't want to suggest anything as she is new to the practice and wants me to try and get hold of the other vet tomorrow. Not overly happy about that as I feel any vet should have been able to come up with a plan of treatment but anyway.....

The bloods showed that lymphocytes are low at only 0.92 which she said indicates not much of an immune system.

So tomorrow,do I ask to start him on azathioprine and leave the pred dose as it is? or do I ask to start him on azathioprine and increase pred back to 12.5mg twice a day? or something else?

Does the low lymphocytes mean something else is destroying his platelets, rather than his immune system? i am quite worried just now.

Just need to make sure I make the right choice and I can't do that without asking you guys first.
Thanks very much in advance, I don't know what I'd do without you lovely people. x

Hi

Reduced swelling is good news.  I hope another 3 days of antibiotics will be enough.  Perhaps they will give you a few more days worth just in case he needs them.  It's always handy to have some extra in the house for emergencies. They can'[t expect his immune system to fight this infection.

Glucocorticoids will produce low levels of lymphocytes and eosinophils, so this is to be expected when a dog is on steroids. Other white cells might be affected too, such as higher neutrophils and monocytes, so I wouldn't be too worried about that.

It is a shame his platelets have dropped, and what-to-do-next must be discussed with your vet.   Consideration to how Merlin is coping with the side effects of the preds has to come first.  If you and the vet think he is coping well then you are free to consider your options, which could be:

To raise the preds up to 12.5mg/12 hrs without Aza and see if there is a platelet increase  in a week.
Raise to 12.5/12 hrs and include Aza in his drug regime. 
Keep the pred dose at 10mg/12hrs - with or without Aza.

Bear in mind Aza won't have any effect for at least 10 days.  Are you prepared to leave the dose as it is?

If you have to keep Merlin on higher doses of preds for a while longer, once the Aza has kicked in it is very useful and allows the steroids to be reduced and still maintain a good level of immunosuppression. Having said that, if you can get away without adding another drug,  then why not?

To me, the drop in platelets indicate remission hasn't been reached yet and the current dose is just maintaining the platelets at this level which is not the objective.

I hope you have a good meeting with your vet.

Jo

Hi

Honestly....I don't have a clue what to do really. My gut feeling would be to go back to 12.5mg every 12hrs and keep him on that dose for at least 21 days,running bloods weekly and if platelets are stable reduce to 10mg every 12hrs for at least 21 days, running bloods weekly and if platelets are stable then drop again. My feeling is that as soon as his platelets got to a decent level they reduced the pred and didn't give it long enough. But I know nothing really.

In some ways though part of me feels it is inevitable that we will have to add another drug...just a feeling but obviously I don't know enough to decide. I don't want the decision to be the Vet's decision or she will just push to add cyclosporin and that's not what I want.

Oh how I sympathize with you. So many decisions to make and all the time worrying about how Merlin is doing and then the added worry of his foot! It would be great to be able to leave it to the vet to make the decisions but you have joined the growing rank of owners who do, unfortunately, have to find out information, check it all out and then try to come to a decision themselves regarding the best way forward to get your dog better.

Personally, I feel the reduction of medication should be slowly when a dog has an autoimmune disease and should be done when the platelets, or red blood cells are increasing and seem to be going in the right direction. I feel too many vets (and owners) panic with steroids. Obviously no-one wants their dog on unnecessary medication but if the reduction is made too quickly then the dose has to be increased again and the dog could end up having more medication then if the dose had been reduced slowly. Obviously if the dog is suffering on the medication then that is a different matter but if it is coping well......

Do not undermine yourself. It sounds like you do understand the general gist of things. No dog is alike so the treatment regime is just a guide. How long has Merlin been on medication? Is it possible just to list what medication he has been on and how long for and the reductions so that we can see at a glance? (I did try looking back in your postings but was not sure exactly how long ago he started medication.)

This is just my point of view, but I would be tempted to start Merlin on Azathioprine (25mg) and increase the Preds back to 25mg daily. Then when the Aza kicks in you can reduce the Preds  if the platelets are increasing. Hopefully he will cope with the medication but if not then it will need to be reviewed.

Merlin had around 14 days on 25mg pred once a day due to bum advice from the Vet. Another Vet at the practice said split the dose and give every 12hrs. After 10 /14 further days his platelets reached 290 at which point they reduced them to 10mg every 12 hrs.
Ten days after reducing to 10mg his platelets dropped from 290 to 160. In the last week they have dropped another 10 to 150.

To recap....approx( i might be a couple of days out,rollercoaster ride etc)
14 days 25mg pred once daily.
14 days 12.5mg pred every 12 hrs
20 days 10mg pred every 12hrs.

The issue I have is that they reduced his pred within a few days of his platelets reaching 290..I would have thought they'd have waited a couple of weeks to be sure they were stable.

Hi

I think your hunch is right.  I can remember Merlin's vet was in a hurry to reduce the preds because of side effects but if you reduce too soon, like Catherine says, you end up giving more steroids than you would have if you had left him on the initial, higher dose for longer.   Still you are where you are and as long as Merlin is coping with the preds, if he were mine, I would raise the preds. 

The following might be a bit confusing but, given that Merlin has been on high doses of preds for some time now it might be prudent to increase the preds and start the Aza, because if the side affects of the preds become too much for him you can confidently reduce the preds knowing that the Aza will have started to take effect. 

If you don't start the Aza and in a week or so time the side affects of the preds  become intolerable (there is no way of telling what will be in a week's time) and his platelets still haven't reached a level you are happy with, then you may have a problem maintaining immunosuppression.  You may then HAVE to reduce the preds and also have the problem of waiting 10+days for Aza or cyclosporin to take effect.

If you raise the preds and start Aza, and in a week (before the Aza will have had any effect) his platelets have increased significantly then you know he is responding  to the preds.

I'm sorry this isn't very coherent but I hope you can decipher this hastily written post.

Jo

Thanks for all the advice.

I rang the Vets but the Vet is actually on holiday until Monday so there will be no change in his treatment until then, I just have to wait until she is back.
When she is, I think I will ask to put him on azathioprine and raise the pred like you've said and take it from there. It probably would be better to get him onto a second drug so we can reduce the steroids before they start to give him real issues. Hopefully his platelets won't drop too much before Monday.

I agree with Jo.  It's never easy unfortunately.  I'm guessing Merlin is about 10kgs?

Merlin is 11.25kg

Hi just an update on Merlin's paw.......his foot is no longer swollen but the toe is still swollen and very red. It smells awful and still has pus coming from it. I've had to put a buster collar on him because he keeps wanting to lick it. I have bathed his foot in salt water twice today and have left it uncovered( had to put old towels over my sofa throws etc in case he leaves yucky ooze on everything.).
I hope with air getting to it and being bathed it will improve. I went back and got more antibiotics for two more days so he has them up until his blood test appointment on Monday night. I will have to ask the Vet if we need to try a different antibiotic since so far the infection isn't clearing up. He is on 150mg Noroclav twice a day.
I have put a little dab of  Manuka Honey Ointment on the side of the infected toe and the one next to it as the leaky pus kept making the toes stick together and they are both looking sore.

Any tips or advice regarding this sort of infection would be gratefully received. I never thought it would be so worrying and I hadn't realised how much it effects healing when a dog is on steroids.
The only positive at the moment is that I have finished working full time and from Monday I am only working 6 hrs a day during the week. This will mean that, whilst being poorer, the dogs will be left alone much less which is such a relief as they have been left 7 hrs a day for the last 8 months. Now they will only be left four and a half hours and the time I will gain with them is priceless.

I'd spray the foot regularly (several times a day) with Colloidal Silver.  It sounds very sore and infected, poor Merlin.

Thank you. Is there somewhere i can buy this on the highstreet? Ive vaguely heard of colloidal silver but know nothing about it.

Poor Merlin. Sounds like a different antibiotic would be worth trying.

Hi

I wonder if there is still something inside Merlin's paw like a grass seed for example?  Soaking it in warm lightly salted water several times a day might draw out the muck and possibly a foreign object.   If you can't get Colloidal silver from a health food shop you can buy it online.

Jo

Thank you. I am soaking it 4 timesa day and thereis the entry hole for the foreign body ,which was in his pad. There are also two other holes,one at the back of his toe from the vet inserting a needle and one on the side of his toe from the needle where they drew pus out. The hole on the side of his toe is still oozing pus and I had hoped that anything in there would have come out by now but the toe is quite inflamed. He's seeing the vet tomorrow at five and i really hope to get some further treatment and hopefully some answers regarding his IMTP. I didnt expect this whole situation to take so long to resolve.

Not something you really want to know (!) but sometimes something like a grass seed can travel further in. Did they x-ray his leg as well as his paw? On the other hand sometimes a wound can ooze stuff if it is not drying out. Maybe he needs to wear a waterproof dressing or boot if he goes out onto the wet grass. I am not sure where you are, but in the UK, even with the sunshine we still have dew on the grass.

Yes, it is bad enough coping with the IMTP without this added worry.

One of my dogs had a grass seed that went in via the foot and ended up coming out on the forearm - but it did come out and hopefully the antibiotics will help to bring it to the surface, or neutralise it, wherever it may be.

Jo

Hi thanks for the replies. The hole in his pad is far too small for the foreign body to be a grass seed. My feeling is that its eithet a sharp piece of grit or maybe glass which I believe would not show on an xray. We dont have grass in our garden and i have been putting a sock on his foot when he goes out there. The paw is not hurting him as he's weight bearing on it ok, it just looks awful but hopefully tomorrow will tell us more.

Has the vet done an FNA on the area of his toe affected ?

I hope you get answers soon

Quote from: Lovemedogs on June 07, 2015, 09:42:06 PM
Has the vet done an FNA on the area of his toe affected ?

I hope you get answers soon

The Vet inserted a needle in two different places and drew out a lot of pus.

Had to pop into the surgery at lunchtime and briefly spoke to my Vet. Tonight we are starting Merlin on Azathioprine and increasing his steroids back to 12.5mg every 12 hours. I still think we might have been ok if we hadn't reduced the steroids so quickly but I'll never know for sure.
I think adding the Aza at this point really is our best option since, like one of you guys said, if he does start to have issues with the pred side effects we could be in a tricky situation. I'm sad to have to add the Aza but I guess this was inevitable.....

I also showed her a picture of how swollen his foot had been and explained that it's still not quite right so  I think we're going to try a different antibiotic today as well.

Positive action for both conditions.  I hope you see improvement soon.

Jo

Thank you :D

Were you prescribed the 25mg tablet of Azathioprine as opposed to the 50mg that routinely seems to be prescribed nowadays? My dog with AIHA was on the 25mg and I do not see any reason to give more than needed unless ideas have changed although it was enough for my 20kg dog. Perhaps other members could advise about the dosage.

He has 25mg. Vet also rang for advice and was told not to increase pred unless todays bloods come back with even lower platelets as he has been on high dose for a while. So we will know tomorrow whether to increase pred. He's had his first Aza tonight. We have to continue with weekly bloods but now every third week do full bloods. Vet said if all his liver readings are high after 3 weeks he will have to come off aza and go on Cyclosporine.

He has also started on Therios tablets(Cephalexin) for his toe which is ulcerated on one side and has pus coming from the ulcer.

With regard to Catherine's comments about Azathioprine, I was told quite a few months ago that my Vet/Cambridge was unable to get 25mg Azathioprine and because of this, Harley was put on 50mg EOD which seems to work the same (at least we have had nothing to make us think otherwise).   However, I have since been told by Asda, that they can get 25mg at the moment - I mention this just in case others may get problems at some stage obtaining 25mg tablets.

We have been on Azathioprine off and mostly on now for around two years or more and I can't say that we have experienced any visible additional side-effects that can be contributed to the Azathioprine...however, I do understand how this drug works and it is something that I hope we will eventually come off.     I asked my Vet what, if we are able to reduce the steroids, would be the drug that they would look to remove first and they told me the steroids - obviously they are more concerned about their side effects.

His liver enzymes will probably rise with the Azathioprine but hopefully not too much and when you start to reduce the medication they will come down again.

I hope the Cephalexin soon helps the ulcer.

I hope that the  Cephalexin works.    However, if the foot is still oozing pus after  several few days on Cephalexin   I suggest that the vet  send the pus away to identify the specific  bacteria  causing the problem.  It may be one of the anti-biotic resistant bugs.  I was treated for one of these last year - after the bacteria was identified by the lab my GP had to get special permission from the Health Dept to prescribe an antibiotic not generally available. That solved the problem for me.


It is such a worry when our dog's immune system is compromised. Minor problems can become serious so quickly.  A tiny scratch can be invaded by bacteria which live in the soil and which don't  cause any problems to a dog with a healthy immune system.   Such a worry having to cope with this before   Merlin's underlying condition has been stabilised. Best  wishes, give Merlin a cuddle from me.

Well this is strange.... Merlin's platelets are at 308 with clumping!
So we've made the decision to suspend use of aza and reduce steroids to 7.5mg every 12 hrs.
The last big drop in platelets was when we reduced to 10mg and he has been on that dose for about four weeks i think. It may be that platelets drop again and then rise as he gets used to 7.5mg.....or I'm simply clutching at straws. The Vet was very happy about the good count but quite puzzled at the fluctuation. I'm not unhappy with reducing steroids tomorrow and seeing how the next two or three weeks go and if the count stays good, reducing again then.
Has anyone else experienced these huge fluctuations in platelets? Or any ideas as to why?

I have not experienced this but I think there are some members of the forum who have....maybe DW? Hopefully someone will be able to advise you.

All I can say is that I would not have rushed to change the medication dosage and would have had another blood test a few days later rather than wait a week to see if the increase was a blip or not. I am sorry I can not be more encouraging and positive. I still prefer to reduce steroids slowly unless it is affecting the dog.

Maybe someone else who has experienced IMTP can reassure you.

How is Merlin's paw?

His paw looks a bit better but still has pus coming from one place.
The reason we are reducing pred is due to 4 weeks on current dose and although platelets have fluctuated,they have remained in normal range throughout. I am willing to try reducing at this stage and expect his platelets to drop in the next week while he adapts to the reduction but if things follow the current pattern,they will drop but then recover if we keep him on the lower dose for two or three weeks. Having never experienced this condition I can only go on gut feeling and vet advice and your advice and reach a happy medium.
His platelets went up to 290 on 12.5mg pred,then dropped to 160 after 1week on 10mg pred,then dropped to 150 on 2nd week on 10mg,then increased to min 308 on 3rd/4th week on 10mg. I can only try reducing pred and see what next weeks bloods show. I have the aza here and the vet and I are agreed not to use it for the moment because if we can reduce pred its worth the shot at not using a second drug if we can get away with it.

I totally agree, having to weigh up all the advice and come to a decision, it is not easy. Also we can not see how Merlin is, so can only go on our experiences and the information you tell us. I do not have experience with IMTP. My dog had AIHA where the HCT (PCV) dropped drastically. With that, the idea was for the HCT to increase back up to the normal range. So with each blood test we were looking for it to increase. Any significant drop was seen as needing to alter the medication dosage or if it was a small one, to stay on the same dosage and not reduce until the next test.

Thank you. Ive only considered the reduction because Merlin despite being happy enough is getting desperately hungry to the point of wrenching weeds and grass from the garden and swallowing them. He's eating the other dogs poo (something he would never do normally) and looks like a little old man. If his platelets had dropped below normal in the last 4 weeks I would not have considered the reduction. I have to try and if I'm wrong then I'm wrong,its almost impossible to do everything 100% right when dealing with the unknown. I won't be considering a further reduction in the near future though as I do understand the need for stability.

Hi Merlin's Mum

Yes definitely I have seen huge swings in platelet count and stabilisation after being on a dose for a while.   I have reduced, experienced a drop in count, remained on the dose and re-tested two weeks later - only to find they had risen.

There are so many possible reasons I have almost given up trying to understand but logically you are right, I am sure that this does happen i.e. the dog needs time to adjust.

I hope what you say is right - as Harley's platelets had dropped a little at the last count and we have decided to stay put on the dose he was on, despite being told it would be o.k. to drop.....no thank you.

Fingers crossed for you and I hope his paw gets better soon.

Hi

Merlin finishes his antibiotics tomorrow but his toe is still inflamed and the back of the toe is still swollen. The ulceration has improved by about 50% but as it's still not fully healed I'm not sure what to do next. The toe itself still feels hot but Merlin is weight bearing on it and running around with no sign that it's causing pain.We are back at Vet's on Monday afternoon for blood test again so will ask the Vet if there's possibly still something in his toe. I'm thinking perhaps a small piece of glass or similar as this would not have shown up in the xray and this actually happened to my little Lurcher who I had a few years ago. In his case he ended up having his toe amputated because the foreign body was never found but had caused too much trauma inside his toe. We suspected glass back then.

Hi

It is a difficult situation.  Logically the antibiotics have probably got rid of the infection, but as it hasn't completely healed it is likely to have a foreign body inside, however soft tissue doesn't heal at all well when a dog is on steroids, so it might be possible that the healing process is retarded and that is why it is still swollen. 

My instinct would be to allow the antibiotics to finish and see if it flares up again - or stays the same.  If it flares up again then it is likely there is a foreign body that has produced more bacteria, and if it stays the same perhaps it is just a lack of healing power that's prolonging the problem and as the steroids are reduced this will improve.

Just my thoughts.

Jo

Thank you. I'm still a bit worried about taking the decision to not use the Azathioprine and hope that my theory regarding fluctuating platelets is correct and that this week his count will have dropped significantly, with a smaller drop next week and then he'll stabilise and they will rise. I will be keeping him on 7.5mg of pred for a minimum 4 weeks and will only reduce again once we've had two blood counts with high platelets.
I just hope there isn't a foreign body because this complicates the whole situation. The Therios tablets have definitely improved the state of his toe much better than the Noroclav did and I can only take hope from the fact he is walking normally. My feeling is that IF there was something in  his paw, he would still not want to put it down. I just wish he hadn't hurt his toe,it would make things simpler.

Is it possible for you to take some clear, close up photos of the sore area of his paw and post them on the forum so that we can have a clearer idea of things please?

This is the best I can do with my phone,it's not really picking up the swelling to the toe...the first picture shows the tiny hole in the pad where the foreign thing went in....the hole looks big in this pic but it is actually very small and I need a magnifier to see in the actual hole( all I can see is a tiny scab)...you can just see the hole in the back of his toe where the Vet inserted a needle to draw out some pus the day he had the really swollen foot.


(http://i10.photobucket.com/albums/a115/zookiheap/11406774_10205299001287892_1388017932095579457_n_zpstxpcuw5s.jpg)

This pic shows the ulceration but it's not so clear but he really doesn't like me doing this so I imagine that area is sore because he runs off down the garden if I try to move the toes to check in between.

(http://i10.photobucket.com/albums/a115/zookiheap/11264860_10205299000847881_327599583073754889_n_zpskowatiox.jpg)

These photos are very good especially the second one in helping me understand what you are describing!

Is there pus still coming out of the hole? It does not look like it. I think the bit between the toes is the problem. I have had something similar looking with my dogs. The dogs feet can get wet (especially on the dew) and they then may nibble and cause the area to go sore and because it does not dry out it can soon become "ulcerated" and "gooey". Then of course it sticks to the side of the other toe and will not scab up. If it does then the scab can get pulled off before it is meant to and once again you have a "gooey" mess. Even though Merlin's fur is short the fur can still cause a problem. Your best bet is to clean the foot in water (holding the toes gently apart) then gently dry with a cool hair drier. Also you need to trim his fur back as much as possible on all the surfaces that connect with the ulcerated place. Fur grows quickly so you do need to keep an eye on if it needs more trimming. It would help if you could wedge some soft bit of bandage or something between his toes (but not touching the ulcer bit) to try and keep his toes apart. Then you have to try and keep it open to the fresh air but obviously stop him or any other dogs getting to it. I do know how difficult it is trying to get wounds healed and at night or when you are not there he will have to have it covered but hopefully it will soon start to scab. I could be completely wrong but at the moment I think it is the fact that the area is not getting air and is sticking to the other toe that is stopping it healing.

Is that white bit in between his toes in the second photo normal?

Hi thanks. No the white bit was 3 times that size and had pus coming out. Its smaller and leaks serum occasionally.

Have you tried giving him homeopathic Silica? it helps push out foreign bodies. I've used it loads of times with success - thorns and grass seeds.  You'd need Silica 30c three times a day for a week.  Make sure you give it into a clean mouth and don't touch the tablets.

Thank you, I will try to get some.

You can get it in most chemists nowadays.  If you've never given homeopathic pills before there are a few rules.  No food with the pills, no food before or after for about 15 mins.  You should ideally tip the pill into the lid of the container, and from there, tip into the dog's mouth.  Of course this all depends on how cooperative the dog is  :P

If they won't take a pill, you can crush it between two spoons and tip the powder in to their mouth. 

Jo

Quote from: Jo CIMDA on June 13, 2015, 08:47:36 AM
If they won't take a pill, you can crush it between two spoons and tip the powder in to their mouth. 

Jo

Ok thank you, I think this would be the only way to get Merlin to not spit it out.

Took little Prince Fluffkin ( my husband's name for him ;D )to Vet's today. His toe still looks inflamed and is slightly more swollen but was looking good on Saturday on day five of his Therios tablets. The Vet and I both feel that there isn't anything in his toe, just that he has no healing ability so he has now started a 10 day course of the antibiotics. I'm hopeful that this is all he needs. The ulceration on the side of his toe is very nearly completely healed. Bloods have been taken today and we should have a platelet count tomorrow. I expect the count to have dropped but have said, either way, we are not reducing steroids until we have two more counts after this one and if they're in normal range then I'll consider a reduction. Merlin is happy in himself but a bit hungry and occasionally thirsty but otherwise seems ok. He had sardines with his tea so it's fishy kisses all round tonight. :D

That's really positive and is a good plan.  He is doing well and seems to be tolerating the preds well too!

Glad he has been put on more antibiotics.  You may have to think about giving some pre and probiotics when this is over.

Jo

Just heard from the Vet's.
Merlin had bloods run on Monday which was day six of 7.5mg every 12 hrs.
Last weeks count was 308 and Monday's count is 302. Hopefully next week will still be good and we'll have some stability.
I am being cautious though as it was only day six of the reduced dose.

Great stuff!

Jo

Having a mild panic tonight. Merlin started frantically licking at his foot so I had a look and as soon as I parted his toes, a load of pus came out of the swollen one. There's nothing coming out now but he cried out when I touched it. As its late I've just cleaned it and put manuka honey on it and a dressing. I'll give it a clean with iodine in the morning and see how it is. He still has a week of antibiotics to go but I do now think there must be something in his toe and my suspicion is still a tiny piece of glass. Unless something changes I will take him to his scheduled appointment on Monday but if it gets worse I'll take him to the Vet tomorrow. He's still weight bearing and no signs of limping which is a good sign.So disappointed as this complicates things for Merlin.

When you said the ulceration had nearly healed a few days ago, did it scab up? If so the scab may have pulled off and become "mushy" again. I do hope there is nothing still in it to complicate matters.

Hi no there was no scabbing at all. The skin had just lost all it's redness and was dry and there was no sign of the oozing and weeping, it just looked like normal pink skin. Yesterday there was a yellow/white swelling which popped and oozed pus. This afternoon I gently squeezed out all the pus,bathed the paw in dilute iodine to help kill bacteria and I also,using a sterile scalpel blade trimmed the thickened hard skin from the pad where the original entrance hole is and by taking this hard area off it has exposed a slightly larger hole in the pad. I used a 10x loupe to examine inside the hole and can see nothing in it. There was a small amount of slightly yellow serum type liquid coming from the hole in the pad when I was examining it. Once the iodine solution had dried I applied a dressing to his paw which I will leave in place until tomorrow at which point I will go back to bathing in salt water. basically we have two scenarios. The first being that he just has no immune system to fight the infection and that's why or secondly, he has something in the toe. It could be either to be fair. The only thing is,he still bears weight on it and still wants to run about. I would be more worried if he was lame on it. Nevertheless I am still worried :-[ :-[

Hi

The mark between his toes look very like an entrance hole to me. It could be a very tiny seed or other foreign body.

My vet did a wonderful thing for one of my dogs once.  She had something similar (though she was not immune-compromised) and my vet managed to syringe a good amount of local anesthetic into the hole which blew up the cavity and whilst the opening was big he put tweezers inside and removed a couple of small grass seeds.  It was incredible, but certainly doable if the vet is experienced and willing to try.  She had no stitches and the wound just healed.  A vet in a million for sure, and it might be worth asking your vet if he/she will consider doing similar.

Alternatively you could try the homoeopathic Silica a Penel suggested.

Jo

Thank you. I had to take James to the Vet unexpectedly this morning and it was the vet who is treating Merlin so I have forewarned her about his toe and she said he will have to have an exploratory op this week to see if they can find something in there. The entry hole is the one on the bottom of his pad but the ulceration etc on the side of his toe is where I think something is trying to work its way out. When he initially got hurt there was just the hole in his pad and nothing else. The day he went lame I looked all over his foot and could only find that one hole and it initially looked like just grit in there. everything else either developed as a result of the injury or in the case of a hole behind his toe as a result of initial Veterinary exploration.I will talk to the Vet and mention what you have said tomorrow when he has his blood test. I haven't tried the silica because I was convinced there was nothing in his toe and to be honest if the Vet is going to do an exploratory op there probably isn't much point now as the op will likely be on Tuesday.

It worked for one of my dogs in a few hours once! I gave it to her for a possible grass seed in between her toes - and when I came home a few hours later her tail was bleeding! there was a thorn half way out!

Hi

Do you think it wise to give Merlin a General anaesthetic at this stage of his immunosuppressive treatment?  If it were absolutely necessary and a life threatening situation then of course you have no choice but I would be worried that the stress and procedure/drugs etc., could trigger autoimmunity and any incisions made may not heal as normal. 

I believe if Silica is going to work then it will do so pretty quickly, so that is really worth trying,  or before making the decision to do a full exploratory it could be worth carrying out the procedure I mentioned previously. 

Good luck.  I hope James is better.

Jo

Thank you. I am very concerned about a GA and need to discuss options with the Vet tonight. It may be that they can gas him down again and use local anaesthetic etc but I have not had the opportunity to discuss everything properly with the Vet as yet. As for James,he is not at all right and he is definitely going to need head,neck and thoracic xrays. He still cries out when he turns his head to the right even though he is on metacam and tramadol. I haven't had chance to get Silica due to either being at work, looking after my poorly husband or looking after my Dad who has Alzheimers. Everything has gone a bit pear shaped at the moment so although it may seem that I am not listening,I am it's just  a bit manic at the moment. If the vet is too insistent about a GA I will get silica tomorrow when I finish work and try it. I'm taking Merlin straight to the Vets tonight so will know more then.

What is wrong with James? Has he recently become ill?

James suddenly developed neck pain about three weeks ago. I took him to the Vet and he had Metacam for a few days and seemed ok but then on Saturday night he suddenly started screaming when he got off the sofa and had trouble turning his head to the right. His muscles that side of his neck are very hard. I took him to the Vet and he has more pain relief but it isn't really working. He is still unable to shake ie if he gets wet etc he cannot do a proper shake because his neck hurts.
He is a  Beagle and weighs 19kg ( although the Vet has said he is not fat, he is very tall for his breed, at 19 inches, despite being a Pedigree Beagle)and he is on Metacam once a day and 75mg Tramadol twice daily but he still cried out earlier when he turned his head to the right. He can turn it left with no issues. He is growly with the other dogs and clearly being careful to protect his neck. I am going to book him in for the neck,head and thoracic xrays the Vet said he will ultimately need but I want to do it the same day that Merlin has his toe looked at so I only have to leave work on one day to drop them at the Vets.

Has he got any other symptoms like a raised temperature, having difficulty eating?

Hi, no he's eating ok and actually wants to play etc but his neck is too sore. I haven't taken his temperature simply because he only has pain if he turns his head to the right without turning his actual neck so i'm guessing the base of his skull top of his neck is where the bone issues may lie.

Both dog's are booked in to the Vet's on Wednesday. James will be xrayed and  if he has spondylosis or arthritis etc he will start a course of Cartrophen. With regard to Merlin, they said he will need to be sedated at the very least in order to keep him still so they can have a good poke at his toe. They will do everything they can to avoid a GA and to try to find and remove the foreign body with minimal incision. I can't tell them no because Merlin needs to have something done as his toe is still pretty swollen and there is still pus.

Hi

It is very unlikely that James has SRMA but if he has a high temperature then it should be considered in the differential diagnoses.

Jo

Steroid Responsive Meningitis Arteritis
Not to be confused with bacterial meningitis.
SRMA is inflammation of the meninges (membrane covering the brain) and peripheral nerve roots, caused by immune mediated infiltration via the spinal cord.  The disease may acute or chronic and is cyclic in nature.   Relapse is not uncommon.

Clinical signs:

High temperature (up to 42C – 107.6F)
Neck and joint pain with stiffness.
Depression.

Diagnosis:  Evidence of immune cells via spinal tap and clinical signs.

Treatment:  immunosuppressive doses of Steroids. Duration: Long term (6 months+)

Thanks. I think the most likely problem with James is arthritis,spondylosis or a herniated disc. We will know tomorrow which,good news or bad,will be a relief. Not knowing is horrible.

Some positive news today. Merlin's platelets are at 260. So we've had 308 then reduced pred to 7.5mg every 12hrs, then 302 after first week and now the 260 after second week. Due to tomorrow and Merlin having possible surgery etc we are staying on same dose for another week and rechecking bloods next Monday. If at that point they are still good,then I have agreed to reduce to 5mg every 12hrs.

Hi

He's not doing too badly, is he?

Good luck with the both tomorrow.

Jo

Quote from: Jo CIMDA on June 23, 2015, 05:27:32 PM
Hi

He's not doing too badly, is he?

Good luck with the both tomorrow.

Jo

No he's actually doing ok if we can get the toe infection sorted. His physique has changed a lot with the steroids and I have reduced his food slightly,although I do wonder whether it will make any difference all the while he's on the steroids. His appetite and thirst have settled back down a little. The platelet drop was only small this week and I had expected it to be worse so i am relatively happy. If the count drops again next week then I won't reduce pred but if its still 260 I will reduce.

Update from a heartbroken owner.....James has intervertebral disc disease...I think that's what its called. Two vertebra are rubbing together and the disc is probably pressing on his spinal cord. An MRI referral to confirm and specialist surgery would be likely but the Vet said even if you have insurance its often not an option because of how serious it is.
I have to be honest and say I would not put James through surgery because he wouldn't cope and we don't have the ability to protect him from knocks etc post operatively,having a household with three other lively dogs.

I have to go and see the xrays at 4pm and collect the dogs. It is likely we will try different drugs to manage James's pain and continue walking him on his harness and feed him from a raise bowl etc but that is all we can do. We had the exact same problem in our Whippet Woody a few years ago and Woody had to be put to sleep but he was aged 13 and James is only 6.

Merlin hasn't had surgery as the Vet does not think they will find anything if it is there. She has said to stop the antibiotics and wait and see if his foot swells again. If it does, then they will try to follow the track of the infection and find whatever tiny thing it is. She said usually the body pushes the foreign item out.
I am going to get some silica for Merlin later on and start giving it to him to see if it will help as I can't keep taking a day off to put him in the Vets for no reason.

I'm sorry you don't have better news for James.  I hope Penel will see your posting because one of her dogs had surgery on his neck last year and it operation was a success.  She had it done at Noel Fitzpatrick's practice.

http://www.fitzpatrickreferrals.co.uk/

Good news for Merlin.


Jo

Thank you. I've seen the X rays and C2 and C3 are completely squished together. There is no disc space at all. After lengthy discussion with the Vet we are treating conservatively at this stage. She said if it was her dog she wouldn't go for surgery now even if he was showing some mild neurological signs. She has ordered a nerve blocking drug for me to collect tomorrow.

I looked back through my Vet invoices from 2005 and found the ones for Woody. He had conservative treatment at age 8yrs for the same condition as James and after several weeks on pain relief we tapered the dose and he was kept happy and comfortable for 4 years until he began to show neurological signs. He started to have serious nerve issues and muscle spasms the last week of his life and we had to have him put to sleep. At that time we were not offered the option of surgery but he was 13.

Having discussed it with the Vet we may actually choose to have surgery later on but because Beagles are known to suffer IVDD, James could end up with another disc going. As things stand the disc space below C3 is very slightly smaller than other spaces as well.

Merlin has had his first Silica 30c tablet an hour ago and I'll get one more down him tonight. I do hope it works so he doesn't need surgery. James had a short walk round the block on his harness just now as he will be rested now for a week as I start him on Robaxin tonight which may sedate him in combination with the Tramadol and Metacam.

I wish you all the luck in the world dealing with these issues woth James and Merlin. Several years ago, one of my nieces bassets ahd major disc issues and was hospitalised for three weeks to allow things to settle. It happened twice to her but she still managed to live to 10 years old which isn't bad for a basset. They sadly lost her to bloat.

Take care now.
Pam

Thank you.
I started Merlin in the Silica on Thursday evening but no sign of anything good happening. His toe is swelling up again and the swelling extends into the back of the next toe. He keeps getting a lump on the side of the toe which occasionally weeps yellowy serum and a tiny bit of pus. The skin in that area is really thin,shiny and smooth and red and purple in colour.

Has the tissue been checked ? An FNA done ? Does there appear to be anything around the nailbed ? I ask this As a couple of my standard poodles have had SCCs.

Pam

Hi,
He had a foreign body enter his pad and severe infection developed amd despite 3 courses of antibiotics it has not improved and we still think theres something in his toe. We've had this before in other dogs but never immuno compromised dogs. I had a lurcher who had to have a toe amputated due to trauma caused by a tiny fragment of stone inside his toe.

I'd give the Silica for a week at least.

So sorry to hear about the IVDD.  As Jo said my whippet cross had surgery at Fitzpatricks last summer, Noel did it.  She has dehydrated disks throughout her whole spine, and one of them had 'exploded' - we could see it all on the MRI - it looked awful, and her spinal cord was under a lot of pressure.  He removed as much of the disk as he could, and put in a disk spacer and pinned it all in place, so she has metalwork in her neck now, between 3 and 4.  It's been a bit of a bumpy road but really she is ok.  She has a permanent limp due to some nerve damage but isn't in any pain and she can still run.  She was 9 when she had the surgery.

Thank you.
Took Merlin back to vets today. They shaved his leg,tried to get blood and just bruised him. Then they shaved his neck and stuck needle in several times( they must have, I can see several pin holes in his neck but they took him to a back room away from me,which they don't normally do)and his neck is all bruised. They also apparently put local anaesthetic in his toe and opened a hole in the side and got some kind of pus out. They had a name for the pus but Ive forgotten what they called it but they said a foreign body could have broken down and come out in the pus. He has a very bloody toe with a pea sized hole in the side where they got the pus out. Am not sure if I should continue with the Siluca or not. Think maybe I should just in case.

I also asked about James and they said he needs six weeks complete rest and I can remove Metacam and slowly withdraw Tramadol and see how he does just on Methocarbamol. Then we see how he is and decide whether MRI and surgery are needed.

I would continue with the Silica, it won't do any harm, even if not needed.

Good luck with the six weeks rest for James.

Thank you. James is the perfect dog,he was the most sensible laid back puppy and remains a very chilled and well behaved boy. Resting will be a breeze for him but mt fear is that he will get fat. Ive got him on low fat food and have reduced his rations but even so,he is a naturally robust dog so likely to run to fat if not exercised which is a worry because excess fat will put more strain on his skeleton.

Just rang the Vet and Merlin's platelet count is still falling :-\ . It's now at 208. We've gone 308,302,260 and now the 208. It seems a steady decline. My overriding concern is his paw. He still has swelling and inflammation and the hole in the pad has opened up today. If he needs surgery he needs plenty of platelets. We're keeping him on 7.5mg pred every 12hrs for a fourth week and reassess at next count. Having full bloods at next count to check everything else is ok.
Is this decline in platelets to be expected? Its not like before when he had fluctuation,its just a slow decline.

Hello Merlin's Mum,

We have been at the same place as you more than  a few times, so don't lose heart but it needs very careful watching.    You are not at the same stage yet as we were when we decided to go back to the I.S. dose of Preds (the first time).  We got down to around the 176 mark before I asked to be referred and even then, the first Vet we saw at the referral clinic still wanted me to reduce.  I think we had got to 120 odd before we acted.
We were actually fooled as well, because despite the fact that his platelets had been slowly dropping like you, when we did drop the Preds, his platelets actually rose on that occasion but it was short-lived and they soon plummeted.  You can be led into a sense of false security sometimes.

The 2nd time it happened, a different Vet at the Clinic put him back up to an IS dose but not the full dose,  we went back to 30mg daily instead of 60mg and that is were we are reducing from now.     These up's and down's can happen - we have experienced this roller coaster ride for a long time but still remain optimistic we can halt the decline.

I wonder if the fact that they have had to try many times to take the blood, might have had an effect on the count?  Probably not but I did wonder.    Did they say if there was any clumping? (We get that quite a few times).
Are you taking any supplementary drugs as well, like Aza's?       We are also trialing Melatonin - it's very expensive, though not as expensive as Cyclosporin  -  I would love to be able to say to you to rush and get him on it but I have no idea as yet, if this is having a positive effect.   I mention it though, as it may be worth talking to your vet about it. 
It's a drug that is normally prescribed as a sleeping aid for humans and the dose we are on is quite high BUT there doesn't seem to be any side-effects from it, though of course, we don't know about long-term use, like with most drugs.    We take 3 x 2mg slow release twice a day (12mg daily - every 12 hours).    I decided that having tried for 3 years to halt the platelet drop, anything, anything was worth a try......
All I can say is that currently we are reducing his preds to a level we haven't been before but, I say this guardedly. as we are still on 50mg Aza EOD and of course the Melatonin.

I am keeping fingers crossed for Merlin, poor boy, he is going through the mill bless him.

Gwyneth

Thank you. Merlin is only on pred nothing else. We started Aza but only gave one dose and then stopped as his count was quite high. Yes there could have been clumping and given the mess they made of his leg and neck I will,in future refuse to allow them to remove him to another room to take blood. If they cannot do it when I am present then frankly, I don't want them doing it. I had forgotten about the possibility of clumping and think its highly likely there was some so in fact his count could actually be higher.

Jut another thought as well......is Merlin receiving antibiotics for his foot and if so, are they sulfa-containing antibiotics?   These can effect the platelets I believe???

Gwyneth

Hi

he's not currently on antibiotics. I put a sterile manuka honey dressing on his foot and I just changed the dressing. The hole on the side of his toe looks a lot better but the hole in his pad is still there. It's hard to say for sure but the toe looks slightly less red and maybe a tiny bit less swollen. I have put another sterile honey dressing on for the next 24hrs and then i will just put a sock on his foot to keep dirt out. If it hasn't considerably improved by next Monday when he sees the vet again I will get them to reassess our options. I still think ultimately they will have to open him up and see if they can find something inside his toe.

Perhaps it is too moist and needs to be left uncovered for a while?

Hi

It's been uncovered for the last 3 weeks to no effect so I've decided to do the opposite for 48hrs with the sterile manuka honey to aid healing. I figured at this stage I habe nothing to lose since it hasn't improved despite being uncovered and subjected to 3 courses of antibiotics.

Has your vet  done any tests to identify the specific bacteria which are causing the infection?

Hi, no because all signs point to foreign body still being present, particularly the duscoloured serum that is constantly weeping from the pad. I will see how it looks tonight and reassess the situation but they wont operate until we know we have got platelet stability.

Sad to report that I need to ring the Vet first thing tomorrow and get Merlin's toe looked at. Its very red and purple and swollen and has serum coming out the hole in the pad and the hole in the side. There's also some internal body tissue poking out of the hole in the pad and the surface of the pad seems to be breaking down. I knew this would happen if they kept leaving it because it happened to my lurcher who I had a few years ago. It ended in amputation and I expect this will too. He is in pain and limping again. Ive bathed his foot in salt water and had no choice but to put a dressing on it to keep dirt out and stop him licking it.

Update.....

Merlin has seen the Vet again. They don't want to operate on his toe unless absolutely necessary. They want to get him on the lowest possible dose of steroids first which depends entirely on his platelet count. Today bloods were done and we get results tomorrow but his neck swelled with blood when it was taken which is probably not a good sign. He has more antibiotics because they want him on them in case they have to carry out emergency  surgery shortly,depending on pain and swelling etc
IF his count is over 208 this week then we will reduce the pred to 5mg every 12 hrs. Will know tomorrow. I have to keep a dressing on his foot so that it is padded for protection. We are on a knife edge in terms of what happens next and all I can do is wait and see which is frustrating.
Just as an aside,my Beagle James is not going to be put through surgery as the condition of his bones in his neck is such that he would need multiple surgeries with no guarantee of outcome. He is on Methocarbamol until such time as either it's not keeping him comfortable or neurological signs are too bad. He is already twitching his head at times but appears in no pain. The Vet's have said to walk him and do everything as normal and just let him be a Dog with what time he has left. I can live with that,I feel it is the right decision for my boy.
Putting him through repeated surgery and all the physio etc and we could still end up in the same place having denied him the quality of life he deserves. Basically his neck has had it and we can't keep living in denial of the inevitable.

Yesterdays count was 258 with some clumping so we are reducing pred to 5mg every 12 hrs from tomorrow.

Did your Vet say how low the Preds need to be before operating?
I think we were at 6.5mg daily (+Aza & Melatonin which stayed the same) when Harley had his op on his mouth recently.....

I think she's wanting to see what his platelet count is today and then next Monday....if the count is good next Monday after two weeks on 5mg twice a day, she will probably want to go ahead with surgery but she didn't say for certain. His toe is actually no better and no worse thankfully so hopefully provided things are good platelet wise, we might have some resolution of his toe in a couple of weeks.
Sadly I now have another poorly dog.... Bill my Beagle,who is notorious for swallowing things,has abdominal pain. He either has pancreatitis or he has swallowed something again. He is weeing and pooing normally and still has an apetite but he's very uncomfortable. Ringing Vet in a minute to arrange an appointment. Can't believe they're all having problems at once!

I'm sorry to hear about Bill.  I hope it is easy to resolve.  You must feel very bogged down with it all.

Jo

Thank you. Bill's temperature was slightly up but the Vet could feel no tensing of his abdomen and in light of him doing a normal poo we are simply giving metacam and starving him until tomorrow night then giving  low fat small meals for a day or so and see how he goes.
Merlin has some more swelling in his toe tonight but at the moment we're still monitoring things. Bloods will be back tomorrow afternoon.

Just had to dash to Vet with Bill. he's vomiting and dropping into the praying position and passing intestinal tissue in his poo.

He now has antibiotics for five days,I have to starve him for 48hrs and he has Tramadol and some GI low fat food once he can eat again.

Merlin's platelet count is back  and it's 277 with some clumping so fairly happy with that although it's only six days since we reduced pred. Next weeks count is crucial.

Hi

Good news for Merlin.

Bill may have pancreatitis.  If this is so he may need to go on a drip to be rehydrated.  Don't hesitate to go back to the vet if you feel he is not improving.

Jo

Thank you. Our Boxer( no longer with us)had chronic pancreatitis and she had to stay in the Vets if she couldnt keep water down. So far Bill is able to drink and keep water down so I hope he doesnt need to go on a drip.
He was really upset when I gave the other boys their dinner and he had nothing but it's for his own good. I really hope he improves in the next day or so.
I am really pleased for Merlin and hope this stability will continue.

Very worried to report that Bill had to be rushed back to the Vet today. He's had bloods run and he doesn't have pancreatitis. White cells were high. Eosinophils and basophils were elevated as well byt apparently not massively high. He is having xrays and ultrasound tomorrow.

Oh Bill, I really hope you're feeling better today?

Bill went back to Vets but Xrays showed nothing,no foreign body and no pockets of gas to indicate the possibility.
They decided not to do a Barium trace as they said it likely wasn't worth doing it.

Bill has Cerenia tonight and then no more to see if vomiting comes back. He has antibiotics,antacids and sensitivity food in case he's having a massive reaction to something in his food. He has half a Diazepam as well because we couldn't manage his pain for two days even on Tramadol and Metacam.

My other concern is that I frontlined Bill the other day( found a flea on him and he was very itchy) with a spot on treatment and that night he appeared to have a kind of mini seizure like episode. Is it at all possible that the Frontline could have triggered this whole horrible episode? I know that sounds wild but I just wondered if it could make his body go a bit weird and maybe set up some inflammation in his gut?

He seems a little brighter this evening but is still uncomfortable and not really himself.

Yes it is possible that the spot on has adversely affected him.

I'm pleased he seems a little brighter this evening.

Jo

merlin went to the Vet today for bloods to be taken. Sadly his toe is now in urgent need of amputation. My worry is that he is going in tomorrow to have this done but we don't know what his platelet count is and we may not know until after he's had the op. When we took the dressing off this afternoon for the Vet to examine his toe,there was a small amount of blood in the dressing. Could this be a sign that his platelets have dropped or simply the fact that the toe is in such bad shape and needs removing? I am quite worried but the infection is going to spread up his leg if the toe is not removed and the toe is all squelchy and revolting.
Feeling very stressed about the situation but feel backed into a corner as we don't have much option.

HI

My hunch is the blood you saw is probably due to the nasty infection.  If it were his IMTP then you will see signs of bleeding elsewhere and it wouldn't be confined to one area.  I'm so sorry it has come to this but like you say you have no option and at least the vets are going into this with their eyes wide open to Merlin's problems.   

They must be pretty sure where the problem lies otherwise they wouldn't have suggested the removal of his toe.  No point in removing a toe if the foreign body, if that's what it is, is elsewhere.

This has gone on for a long time and Merlin (and you) need it to be addressed.

Good luck tomorrow.

Jo

Thanks Jo. We are all certain the foreign body is glass or a tiny sharp piece of stone and it's definitely still in his toe. We had the same issue with a previous Lurcher. Although he didn't have IMTP, the foreign body did so much damage to the inside of his toe it had to be removed.

Thank you for the reassurance. There are no bruises on Merlin anywhere and I've checked his gums etc and absolutely no signs of bleeding. we're keeping him on 5mg pred twice a day for at least another week to give him time to get over surgery etc. If his count IS good next week then we may look at a further reduction.

What would be the likely dose at next reduction? would it be 2.5mg twice a day or would they make it 5mg once a day?

Hi

Not taking into account the healing problems associated with surgery when a dog is on steroids, if Merlin were mine I would take the reduction slower because you have previously had problems with a drop in platelet count.  Assuming he is coping with the steroids I would drop to 7.5mg in the morning, with a gastroprotectant.

I hope all goes well.

Jo

thank you. Depending upon the healing process I will consider keeping him on 5mg for two more weeks and then look at the reduction. Thanks again for the advice, I will speak to the Vet about the eventual reduction to 7.5mg once a day etc. I am more than happy to reduce slowly as this has been such a stressful few months. I'd rather keep Merlin stable even if it means the healing process is slower,than risk a relapse of platelets at this stage. I'm certain things will improve once the toe has been removed as I'm convinced the presence of the foreign body is what has stopped the healing to such a great extent etc. this is exactly what happened with my Lurcher but it didn't go on so long before his toe was amputated as he wasnt immuno compromised.

Merlin has had his operation. Apparently they consulted a specialist before commencing to get the pre med and analgesia correct. Unfortunately during the operation Merlin bled a lot and had to have a tourniquet applied and his toe had to be sewed up very fast to stop the bleeding so apparently the stitching isn't very neat! He has both dissolvable sutures and ones which need removing. He took his dressing off after the op and had to have it redressed. He has a huge buster collar on and is not the least bit happy tonight. He has to go back on friday for a dressing change and post op check after which point I will do the dressing changes myself as apparently he will need them done for a while.
The platelet count for yesterday was 247 which is good for 5mg pred twice a day. He has antibiotics.
The only thing i am surprised about is that they haven't removed the entire toe but just to the first joint....I have not seen it but this is what the nurse told me. My concern with this would be that surely the unsupported remainder of the toe will catch on things if he tries to run? Am really not sire about that though.
I am 337 pounds lighter and we still have a heck of a way to go yet. I think so far this whole illness has cost close to 2000 in three and a bit months...this is just for info in case others wonder how much this sort of thing costs......more than I expected  ;D

Phew, life isn't easy for you, is it? 

Did they find a foreign body?  Perhaps they did and this is why they only removed part of the toe.  They must feel happy they have solved Merlin's problem.

247 is a good number.  Fingers crossed.

I would certainly be giving him Arnica tablets, or Ainsworth's do a surgery remedy.

Jo

They didn't look for the foreign body,simply removed his squishy infected toe. The toe could not be saved so they didnt feelit was worth looking. I can't explain exactly but the actual toe from the second jount to the base of the pad was a mess and had been for several weeks. There was some swelling and redness up to the base of the toe where it joins the foot but the infected area was just the area inside the pad and up to that first joint. Any foreign body was trapped inside under the pad but within the tissue of the toe..if that makes sense.
I will get some arnica tomorrow.

(http://i10.photobucket.com/albums/a115/zookiheap/11703330_10205593024838297_6303504585567579210_n_zpsrpgqq8xc.jpg)

Poor Merlin, that collar must be horrible to wear.  I do hope it heals well and you can take the collar and the bandage off soon.

Jo

Thank you. He is a nightmare for chewing and licking and he already had his dressing off even before leaving the vets,so the risk without the collar is too great. The last thing he needs is to interfere with his stitches etc. I do take the collar off when we're together and he can be watched. I'll be interested to see his toe at the dressing change tomorrow. I really hope it will be starting to heal.

He's through the operation ok now so that's great.  I really hope this heals up nicely and quickly for you both!

It has been good to read about Merlin as I have been through similar experiences with Matisse and it is good to compare.  Hope he is still improving as the thread didn't seem to carry on unless I am just not navigating my way round this site yet (my first day!).

Thank you. this is page 12 of the post but I must admit my other dogs being poorly kind of sidetracked things.

Merlin is doing ok. He is still on 5mg pred every 12 hours, seems happy enough. He has gained some weight and now weighs in at 12.7kg so I have him on a low fat veterinary diet as I really don't want him to get too fat especially whilst having his bad paw.
We have his first dressing change today so I will see his foot for the first time since the toe amputation. I will be doing the dressing changes myself after today but the Vet needs to see it as it is the first post op check. He has muscle wastage and looks much older than his four years but all in all he's in pretty good shape considering.
Merlin is an amazing little dog and has taken everything in his stride. He has cooperated totally and been a model patient,never once protesting or struggling at all. The Vet and Nurses love him because he has been so easy to treat. He's a real little tough guy and has surprised us all.
We know that this isn't over yet and that we still have to either get him off steroids or get him on a lower dose and keep him stable etc but given how things were at the start,when we didn't know if we were going to come home and find he had died,he has done well and come a long way. it is only really thanks to the advice from people here that he has been able to get the right treatment and the right care and for tat I am extremely grateful.
I will be looking to reduce pred to 7.5 mg a day from next Tuesday IF his count has not dropped again.

Ah yes I see now that I only read Page 1 and then went onto the next topic instead of page 2.  I will read the rest of your postings a little later.  Perhaps you can just give me one quick answer though - did Merlin's eyes become sensitive to light?

No not that I noticed but he had a considerable amount of bleeding inside his eyes and even now one eye hasnt completely reabsorbed the blood so this will have reduced the amount of light hitting the back of his eyes.

Have replied to your other post but having problems with sending it.  It is being sorted.

Well Merlin has had his first post op check and dressing change. his half toe looks awful,its red and swollen but both Vets had a look at it (the Vet who did the op and the Vet who did the dressing change)and they said they were happy enough with it. He had his paw cleaned up a little and a fresh dressing applied. He goes back on Monday for bloods to be done and a new dressing change. I will let them do that one as they will reassess and probably give a further course of antibiotics then but i will take over dressing changes then. i've been told to expect it to take weeks to heal given everything and given the fact hes on steroids.

Have finally had chance to read all the other pages of your postings and had no idea how many different problems you were dealing with.  You must be absolutely exhausted both physically and mentally.  I do hope today's visit to the vets brings better news for Merlin.

Quote from: Savannahk9 on July 27, 2015, 09:43:25 AM
Have finally had chance to read all the other pages of your postings and had no idea how many different problems you were dealing with.  You must be absolutely exhausted both physically and mentally.  I do hope today's visit to the vets brings better news for Merlin.

Hi thank you but actually I'm fine. I'm a very resilient person and all these problems are only an issue because it is sad for my dog's. Losing James is going to be terrible because I wanted him to live into old age but I cannot change the hand I have been dealt,only make his life as fun and comfortable as it can be with whatever time he has.
Eventually, Merlin should be stable,whether on drugs or off them completely and only time will tell with little Bill.
Sometimes I think that the poorly dog's end up with me for a reason...no idea the reason but on a certain level I cope completely and am able to deal very calmly with each crisis. I'm not much of a people person but I understand dog's in a way that perhaps some people don't, although I do worry about them in my head but being able to post here and get some reassurance and/or advice has been invaluable.

Well Merlin went to the Vets for bloods and a dressing change today. Very very disappointed to report that his stump of a toe is infected. It has started to smell horrible and has discharge coming from it. There is no necrosis which the Vet felt was a positive. I have to do daily dressing changes until Friday and we are using Manuka Honey dressings to help draw out the infection. He has a further course of antibiotics and if the foot doesn't smell better on Friday then he needs to go back. If it smells ok then we put a fresh dressing on it and leave it on over the weekend and he'll be reassessed next Monday. Please think positive thoughts for an absence of infection by Friday because I'm not sure where we go from here. There is no foreign body in what remains of his toe but part of me wonder whether the original infection is still there and we're just not overcoming it because of the steroids.
If his platelets are good tomorrow we are reducing pred to 5mg in the am and 2.5mg in the afternoon rather than 7.5mg once per day. The Vet preferred to split the dose.

Sorry things are not going well with Merlin's toe. I will definitely keep all my toes and fingers crossed for a good outcome for you on Friday.

Hello

I am keeping everything crossed for Merlin's recovery bless him...it just doesn't seem fair does it.

Give him a cuddle from me please x

Quote from: DW on July 28, 2015, 12:49:17 PM
Hello

I am keeping everything crossed for Merlin's recovery bless him...it just doesn't seem fair does it.

Give him a cuddle from me please x

Thank you, consider the cuddle given.
I have just changed his dressing again but the toe looks terrible. The problem we have is that the wound needs to be covered to keep it clean and prevent infection but keeping it covered has kept it moist and warm and therefore a perfect state for infection. I do think that the Vet was mad to keep half the toe. To my mind he should have amputated the whole thing,that way all the inflamed infected tissue would have been removed and they would have been suturing fresh skin and we would only have a wound to worry about. What they actually did was remove half the toe,leaving themselves inflamed and infected tissue to sew back together.
Looking at the wound today I feel certain he will be going back on Friday,there is no way in this world it will be free from infection in 48hrs,it's awful. Merlin himself is not very happy and I suspect he is in some pain.

Sorry to hear that.  Perhaps their decision was based on him having other problems but it does seem strange as the last thing he needs is another op. 

Is he on pain relief? poor lad.

No they said he can't have any as he's on steroids. The only thing he had when he had his op was a Vetergesic injection but it only lasts six hours.

i've re-dressed his foot again just now and the stump is quite puffy and there is discharge and he has an ulcer on the side of the stump as well where they have put some dissolvable stitches. I have put cotton wool inbetween his toes to stop them getting any worse and have used another manuka Honey dressing. The foot doesn't smell so bad but I'm not sure if that's the Honey making the smell seem less obvious. It still doesn't smell nice but not as bad. I have booked him in to see the Vet on Friday as well as next Monday.

He should be able to have Tramadol? I"d ask if I were you.

Finally got Merlin's platelet count from Monday's bloods. 246 so I am reducing pred to 5mg in the am and 2.5mg in the afternoon.

Strangely the Vet who texted me the result said to reduce to that dose and keep reducing every 5 days? surely that can't be right can it?

I was thinking of carrying on with weekly bloods to check the count and reduce after 14 days on the new dose each time unless platelets drop significantly. I'm a bit worried that he's told me to reduce every five days, surely that could put Merlin into a bit of a crisis if past experience is anything to go by!

I wouldn't reduce every 5 days either.  That barely gives the body time to adjust to the new dose.  I think you should trust your instincts on this one.  Is it because of his toe healing though that they're hurrying up the reduction?

No idea if its about his toe,it wasnt the Vet who usually sees Merlin. I will talk to her when she takes blood off him on Monday. I want to do 14 days on each reduced dose with the weekly platelet counts. To my mind he's on. Fairly low dose now so possibly will have some improving ability to heal. He is on less than half a mg per kg twice a day. His stump still looks yucky but it no longer smells. When i change his dressing tomorrow I have to decide whether to change for a dry dressing and leave it covered until Monday like the vet said or go back to the vet tomorrow. She said only go back if it still smelled bad but it doesnt so i almost feel i should redress tomorrow as advised and go back Monday. Its difficult to know what to do for the best.

If the weather is dry I'd consider leaving it dressing free so it starts to dry out.  Buster collar or inflatable collar if necessary?

Hi

He has a buster collar on  and I did want to leave it uncovered  but the Vet's are adamant its safer to keep it covered. I might try a few hours tonight keeping him crated on some deep Vetbed to protect it. I've asked my husband to take a look at the toe...he doesn't know anything of veterinary things but if he thinks it looks awful then I will be taking Merlin to the Vet tonight. It's one of those situations where I have looked at his toe so much I just can't see the wood for the trees, so my husband is my sense check.

Good plan.

Hope Merlin's toe is looking and smelling ok today.  Not quite the same thing I know but two weeks ago I had two basal skin carcinomas burned off - one on my wrist and one on my back.  They are not healing and I decided today to just leave all the dressings off and let the air get to the wounds.  I tried the things they recommended i.e. vaseline and iodine and I also tried Manuka honey.  Nothing seems to improve them so I am now just seeing what happens with good old plain fresh air.  Hope we both succeed with this :-)

Thank you. I hope your issues improve with the fresh air. I have actually changed Merlin's dressing today and put another dry dressing on ie no Manuka Honey. I decided to re-dress his foot just due to risk of further injury as it needs protecting and he's too silly not to hurt himself. I would like to leave it uncovered but I think i would be putting him more at risk by doing so. I will assess again tomorrow and take him to the Vet's in the morning if I'm still unhappy with things.

Yes it is so easy to cause more damage by knocking it and especially the foot.  Good luck with it.

Merlin has been back to the Vet's tonight to have blood taken and his paw checked. As it's 13 days post op, the Vet has removed all the stitches from the toe. There is no longer any visible infection but the stump is raw and bloody looking so I have put our Giant puppy crate up and Merlin has his foot uncovered as per the Vet's instructions. We need to let the air get to it and see what happens next. The unfortunate thing is that they have only amputated half the toe and as the ligaments have stretched in that foot,the half a toe touches the ground. I will need to cover his toe when he is let outside and i can take him for short walks so long as the paw is covered and well padded. I hope that the skin on the underside of the stump will thicken up and toughen up with time otherwise he will end up having to wear a dog boot whenever he is out and about.

Ive just had Merlin's platelet count back and worryingly only five days since reducing pred his count has gone from 246 down to 188. Previously the drop in platelets has always been a good 10 days after reducing pred which is why we kept him on each dose for 21 to 28 days.
I'm desperate for his toe to heal before we have a platelet crisis. I guess I can only wait and hope that next week the count isn't any lower.

Re: hello from Merlin and his mum
« Reply #198 on: Today at 03:20:09 PM »
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Hi

I know that you are worried and will be for a while, after surgery - I was too, expecting the surgery to have had an impact on the platelet count.

Purely by my own experience I would mention a few things...

Firstly, you say that you normally see a drop in platelets after a 10 day period......it might well be that the platelets on those occasions actually were dropping prior to the 10 day test but you would have only seen the drop when you tested (if that makes sense) i.e. had you have tested at five days then, you may well have seen a drop??(Possibly?).

The other thing is, that the drop you are talking about isn't huge....though I know it seems that way.  I have been exactly the same when we have seen drops of 30......terrified that it was a sign that things may be taking a downward trend.    Yes, realistically that may be so but not necessarily.     A few months ago, we experienced a drop of 100 in Harley's platelets, then, two weeks later (I normally do a test after two weeks rather than a month if we have seen a serious drop) - they had risen again.

There is always the question about clumping as well.   Do your Vets always tell you when they give you the results, if there has been any clumping?  If not, I would always ask.

I'm sorry but I can't remember if you had said that Merlin was on any other support drugs.   I found that Azathioprine does help whilst trying to reduce the Preds and I wonder if it may be something your Vet has considered?

The other thing I wondered and my lack in knowledge probably means I am totally wrong here...but post op, I would have thought it relatively common for platelets to be lowered, depending on blood loss?    Also, Merlin has had an infection as well and again, I wonder if that has had an effect.

I don't know what margins your Vet uses,   mine is  (low)150 - 400(upper) so 188 isn't bad but trends need watching as you obviously know.
It's a difficult time, as you need the healing process to continue well but at the same time can't afford to rush the reductions either, or you could be back to square one.
I would certainly ask the Vet about support meds and IF by being on them, such as Azathioprine, if that would be detrimental to the healing process?  I wouldn't think so.

As I said, these things I have said are only personal finding but may help.  Finally, this may help you if I tell you that when Harley had his op in April this year, we did a platelet check and post op (two weeks later) we had dropped by 60.  A month later, they hadn't increased BUT they hadn't dropped either.    We still reduced, because they had stayed the same (but only by .5mg) and a month later, the platelet count was roughly the same again.
I am wondering if, we might have reached a point, whereby Harley's 'normal' platelet count has been achieved?   We won't know until we drop further but I am totally with you at this time, it is such a worry.....

I hope you get a better result in two weeks (presume you will re-check in two).

Gwyneth

Thank you for your reply. We check his platelets weekly and have been doing so since April as we have seen big swings in platelet count so weekly testing seemed the safest option in terms of monitoring the situation. we tested last Monday but didnt get the result back until Thursday at which point we decided to reduce pred to 5mg in the morning and 2.5mg in the evening. This Monday which was five days after reducing pred we had the 188 count.

I did just text my Vet a short while ago and ask if it would be ok to bathe Merlin's paw in salt water as his stump of a toe is cracking and bleeding. She texted back and told me this was ok and also if needed to go back to applying dressings but change them daily. She also said that his platelet count did have clumping so the 188 is the lowest value which is a little bit more reassuring. I guess I am worried because in the initial stages of this condition,Merlin was gravely ill and we very nearly lost him.
I cannot express the horror of watching swellings appear on your dog's body only to watch the swellings disappear and become patches of bruising. This was where blood vessels were bursting. His eyes were also half filled with blood and it took until three weeks ago for that to be completely reabsorbed. I'm a very strong person but I really never want to see that again. With everything that has occurred in the last three months and with the length of James's future still unknown, I guess the thought of Merlin slipping back into problems feels like too much.

we have been reducing pred by 5mg each time but last week I only reduced by 2.5mg and any subsequent reductions will be the same or less depending on how he goes. Thankfully the infection appears gone from his toe and it's just a bit red and swollen...and cracked and bleeding but no pus and no nasty smell.

I really don't want to put him on another drug along with the Pred if I can help it and I am determined to keep him on his current dose of pred long enough to be fully satisfied that we have stability in his platelets. Once he's down to a smaller dose I may consider fortnightly bloods and eventually monthly but weekly tests at the moment seem the sensible option.
Thank you for your good wishes and for sharing your experiences.

What a bad time you and Merlin are going through.  I am so sorry there is nothing I can add that may help but just to let you know that I am thinking about you and hoping that things will improve for you very soon.  He has come a long way since the days you nearly lost him and you just have to hang in there until you come out the end of a long tunnel.  There is always light at the end you know.  :)

How is Merlin doing today?

He's ok in himself and although his stump of a toe is very inflammed and swollen it is slowly beginning to heal,apart from an ulcer on the side where the next toe sits against it. I am putting dressings on during tge day but uncovering it at night which seems to be helping. Next weeks platelets will be crucial but so far no worrying signs. Despite being on a diet he is putting on weight which is disappointing as I was hoping he wouldn't. It hasnt helped that he's not able to be walked and has't been for around a month as the toe ha s been too bad.

Merlin's stump remains incredibly swollen and the skin has broken down a bit. I'm back doing daily dressing changes. His platelets have dropped unfortunately and are now at 174 with no clumping. I am beginning to worry again but it is 12 days since we reduced Pred so I guess the lower platelet count was to be expected. I so hope they don't drop further next week as the thought of starting all over again is a serious concern given the state of what's left of is toe. :( :(

Poor Merlin, what a worry for you.
Have you tried spraying his toe with Colloidal Silver? I know you tried the manuka honey dressings.

Yes we tried colloidal silver prior to amputation. i have just noticed he has an ulcer on a rear paw on the side of a toe. Basically, the outer toe nail must be catching on the side of the next toe and has caused it to ulcerate. I think I need to allow the nail on the outer toe to grow a little longer so it doesn't catch. I've wrapped a plaster round the toe to try and protect it but it's a nasty ulcer. :(

 :(  poor ol' Merlin.

Merlin is having a crisis and is on his way to the Vet. His paw is swelling with blood. No idea why but when I changed his dressing his stump looks all wet,infected and broken down. I am totally stressed with this whole situation and no longer know what to do.

Update:- back from Vet's and merlin is back on antibiotics and back to Manuka Honey dressings every day and booked in to have the rest of his toe amputated in two weeks time provided his platelets are high enough.

So sorry to hear this, poor lad.  I hope things look a bit better tomorrow.

Just changed his dressing again and if anything,it is looking worse the next toe is considerably swollen and the stump is breaking down further. I really hope over the weekend that the antibiotics will kick in but it's really not looking good at all.

 :(  how worrying.  I'm so sorry he's having to go through all this.

Hi

I've been away on holiday and I am so sorry to come back and read that Merlin's toe isn't any better. Is he still on daily pred?  I wonder if this could be inhibiting the healing?

Jo

Yes he's on 5mg in the morning and 2.5mg at night. The end of the stump has finally healed but he has infection and ulcers on one side where it touches the next toe. Vets again today so will update later.

Been back to Vet's and there are some signs of healing on the end of the stump still but it does look pretty red and angry still. There is still ulceration and it's fifty fifty as to whether we'll need to operate next week to amputate the rest. i'm continuing with Manuka Honey dressings for 48 hrs and then just bathing in salt water and dry dressings changed daily and see what happens. He has antibiotics which will last until Sunday. In an ideal world we could do with keeping his toe uncovered but it's way too early to risk allowing him to walk around without it protected. He had a small knock on his shoulder with a tiny nick which also appears infected and the ulcer on his back paw was infected as well. both of these injuries look a tiny bit better.

Fingers and paws all crossed!

It really sounds like the steroids are inhibiting healing.  Is there any chance the steroids could be dropped sooner than planned, even if it means introducing another drug to control his IMTP? 

It just worries me that he could go through another operation with further amputation and that also won't heal.  Back to square one, or minus one!
Poor lad

Jo

Hi,
If his platelets are in the mid 200's tomorrow we are reducing pred to 2.5mg twice a day ( currently 5mg in morn and 2.5 at night. I'm going to go back to bathing his paw in salt water and we're going to continue antibiotics. I'm hoping with all my heart we can reduce pred tomorrow. I actually don't want them to operate again and am hoping to hold off for as long as possible doing everything I can to improve hus chances of healing.

Merlin's platelet count has come back today at 221 so I have decided to leave him on his current dose. I wanted them to be a touch higher in order to reduce today so I want to wait and see what they're like next week. I just want to see some stability as the next reduction will be down to 2.5mg twice a day and I suspect reducing to that dose, we may see a big drop in numbers.

He was 177 last week,ten days after dropping to 5mg in the am and 2.5 in the afternoon( previously 5mg twice a day).

I have stopped applying Manuka Honey Dressings and he is now on just dry dressings. His toe looked no worse today.

You should be quite pleased with that result.

Jo

Quote from: Jo CIMDA on August 19, 2015, 08:52:17 PM
You should be quite pleased with that result.

Jo

Ok, thank you. Having never been through this before, we have no idea what to expect or what is good or bad. Not knowing what to expect as we get lower and lower with the pred is a bit worrying.
Merlin peed on his bandage so I had to change it again and actually his toe (whats left of it) looks a bit better yet.
The only real negative is that he is getting fat. His shape is noticably changing. I really hope we will be able to get him back in shape again. Not being able to go for a walk is not helping but we can't risk damaging his toe further.

Hi

It is difficult to know what Merlin's 'normal' platelet count is because it was not measured before he got IMTP, also sighthounds have a much lower platelet reference range.  See the links below.

Glucocorticoids raise platelet count so it is perhaps expected, as the dose is lowered, that his count may fall back to what is normal for him.

Glad his toe is looking better.  I have known dogs to have these healing problems when they are on long term steroids.  It is easy to think it might be something else in his toe when in fact it is likely to be  a retarded healing problem.

Jo

http://sloughi.tripod.com/preserving/haematologybiochemistry8sighthounds.html

http://veterinarymedicine.dvm360.com/idiosyncrasies-greyhounds-can-affect-their-medical-care

Thank you very much for the links,I will have a good read tonight.

Having just re-dressed Merlin's foot, it does look considerably less inflamed and where there were two open ulcer's we now have some scabbing over.There is still a bit of infection but nothing like there was. I'm certain we are turning a corner with his toe(what's left of it)and am increasingly hopeful that he may not need to have the rest of it removed.

I am going to reduce pred next week if his platelets are still about the same as I really would like him either off them altogether or on a lower dose soon so we can address his weight gain and muscle wastage.
I know this journey is likely to be life long but it would be nice to get some semblance of normality.

*whispers in case she puts a hex on things*...We have healing.The inflammation has reduced by 70%. The swelling has gone down considerably and we have one small scab and one tiny ulcer but the change in the last few days has all been positive. I almost daren't hope that what I'm seeing is really happening. Please keep everything crossed.

My only slight worry going forward is how flat footed he is and whether the stump will get injured just from walking once he's free of dressings.
But right now I want to think positive.

That's great news.  Perhaps he has turned the corner.

Jo

(https://farm8.staticflickr.com/7359/13889914237_de6f4f8672.jpg) (https://flic.kr/p/naprzX)Paws crossed! (https://flic.kr/p/naprzX) by Penelope Malby (https://www.flickr.com/photos/penel/), on Flickr

I love it Penel!

Jo

 8) 

I could use some advice please. Merlin's platelet count for this week is 174 with small platelet clumps. The Vet is saying to go ahead and reduce from 5mg in the morning and 2.5mg at night down to 2.5mg both morning and night. Do I take this advice and go ahead?
I'm scared but he has been on current dose for four weeks and we've had counts in the normal range all four weeks.

Thank you.

Hi

If there are platelet clumps then this number is the lowest it could be and the actual count is likely to be very much higher. 

The vet is confident that Merlin's platelets are stable but if you are not sure it would be worth having more blood taken, from the jugular and perhaps using a larger needle, to see if you can get a better sample and an accurate reading on which you can base your decision.

Jo

Hi

The blood was taken from his jugular yesterday. It always is. I have gone with the advice and today he started the 2.5mg twice a day.
I have everything crossed that everything remains positive. At least this is positive in terms of his toe healing.

I do have another question actually.......If this reduction to 2.5mg twice a day proves to be ok and his platelets stay good,what should the next Pred reduction be? I will likely keep him on this current dose for 3 to four weeks but am wanting to prepare myself for the next drop in steroid dose.

Thank you

HI

When you get down to a low daily dose it is better to be given in one go in the morning because the effect will be greater.  See this link.

http://www.drugs.com/pro/prednisone-tablets.html

The maximal activity of the adrenal cortex is between 2 am and 8 am, and it is minimal between 4 pm and midnight. Exogenous corticosteroids suppress adrenocorticoid activity the least when given at the time of maximal activity (am) for single dose administration. Therefore, it is recommended that prednisone be administered in the morning prior to 9 am and when large doses are given, administration of antacids between meals to help prevent peptic ulcers. Multiple dose therapy should be evenly distributed in evenly spaced intervals throughout the day.

When the 3-4 weeks is up then you can assess it again, but you can go to 5mg every other day (it depends on how quickly you need to reduce the dose in order for his body to return to normal).   It is when you achieve every other day dosing that you will see a huge difference and a return to near normal behaviour etc. 

If that is too quick then you can drop the dose to 4mg a day, then 3mg a day etc......then go to every other day dosing. 

I would definitely give it in one dose from now on though.

Jo

Ok thank you very much, I'll give him 5mg every morning from tomorrow morning. I'll see how we go with platelet counts and if they remain reasonable I will consider 5mg every other day once we get to the next reduction.

Very disappointed owner this morning. After 24 hrs with no dressing on his paw,Merlin's toe stump is badly bruised and swollen and confirms the fact that he will have to have the rest of his toe amputated. I'm pretty annoyed as I did say from the outset that I'd expected the whole toe to be removed and was shocked to see that only half of it was taken off. So we're back to square one with the toe and I need to book him in for amputation again and repeat the last two months :'( :'(.
This is assuming that in three weeks time,when I have a few days off and the surgery can be scheduled,he has a good platelet count.
I don't know if I'm more sad or more angry,if I could see that this was going to be the outcome,why couldn't the Vet?

Oh no I"m so sorry.  How disappointing for you.  Poor Merlin.

Thank you.

Took Merlin back to the vets today and a different vet saw him and took blood. This was the vet who performed the surgery on Merlin's toe. He said that perhaps he should have taken the whole toe off at the time but he is not prepared to operate on Merlin again unless he is off steroids because he bled "like a stuck pig" and he could not see what he was doing so he sewed him up quickly last time!
Do steroids cause excessive bleeding? This is something I genuinely don't know. The vet said he had a tournique on Merlin's leg for the maximum allowed time and still he bled which is why the sewing was very haphazard.

To be honest I'm not entirely happy but the vet wasn't in a particularly good mood so I kept my feelings to myself. I have already spoken to the vet I usually see and two weeks ago she said she would operate on Merlin and amputate the rest of his toe and she didn't mention anything about waiting until he was off steroids.

The vet today also said that rather than making the next dose of pred an every other day dose,we should reduce to 2.5mg once a day in the morning and then after a few weeks go to an every other day dose.Now this sounds ok to me but I'll take any advice on offer!

Thank you and thank you for bearing with me so much on this loooong journey. X

Hi

This is very disappointing for you but my feeling is I would wait until Merlin was off the steroids too if that is at all possible.  Steroids inhibit healing and I feel this is probably the reason why Merlin's toe isn't healing properly, and this leads to the question, if Merlin has further surgery, will that heal or will you be in the same position you are in now - or worse?   

As far as I know steroids don't cause excessive bleeding, in fact it increases platelet production which can have the opposite effect. 

Going to 2.5mg a day before going to every other day dosing is a great idea, that is assuming you are not in a hurry to get Merlin off steroids so that his foot has a better chance of healing.  It depends on which problem is most urgent.  It is a difficult situation.

Jo

Really difficult, and I"m sorry for you that today was such a negative visit to the vet.  They're lucky you were patient with them, I'm not sure I would have been!

Quote from: Jo CIMDA on September 01, 2015, 10:00:08 PM
Hi

This is very disappointing for you but my feeling is I would wait until Merlin was off the steroids too if that is at all possible.  Steroids inhibit healing and I feel this is probably the reason why Merlin's toe isn't healing properly, and this leads to the question, if Merlin has further surgery, will that heal or will you be in the same position you are in now - or worse?   

As far as I know steroids don't cause excessive bleeding, in fact it increases platelet production which can have the opposite effect. 

Going to 2.5mg a day before going to every other day dosing is a great idea, that is assuming you are not in a hurry to get Merlin off steroids so that his foot has a better chance of healing.  It depends on which problem is most urgent.  It is a difficult situation.

Jo

Thank you. His toe has actually healed completely now. The issue is not the lack of healing but rather the fact that every time he takes a step,the half a toe hits the ground and gets bruised which causes purple discolouration and swelling. The actual toe itself looks good first thing in the morning before he bears weight on it. I have to keep a padded dressing on his paw to minimise the bruising but even then it still happens to a degree. I'm pleased that the steroid dose suggested is acceptable and will hold out until he's off the pred before doing any more to his toe.

Merlin's platelets are at 187 no clumps. That's seven days after reducing pred to 5mg per day.

Merlin's platelets have dropped further and are now at 157 no clumps. :( Keeping him on 5mg once per day.

Have just caught up with Merlin's progress and I am sorry to read of the awful time you have been having.  What a quandary you have been in to know what to do.  I would have thought the Thrombocytopenia was sufficiently under control with the steroids by now not to cause excessive bleeding if the operation was done.  However, if the paw is healing now I guess it is really just a question of not doing further damage to it.  I know racing greyhounds do a lot of damage to their feet, I wonder if it might be an idea to contact a specialist vet (I may be able to find the contact details of one I know of) and see what they put on their paws.

Hi

Good news over Merlin's paw in that it seems to be healing, although I appreciate there are other issues that need addressing....

As far as platelets are going, they are still at a healthy score given that he is only on 5mg I'd say but obviously there are concerns that the count is dropping without clumps.
I know that when this happened to me, I was told that just maybe his own platelet count is actually levelling at what is his personal level i.e. Merlin's 'normal' platelet count (for him) might be around what the count is at the moment.    With Harley it did continue to drop however and I say this purely to enquire if your Vet has suggested an additional drug such as Azathioprine, which may just offer some support as the Preds are reduced.   

I can't remember if you are in the U.K but I wonder if it may be worth your suggesting the drug that Harley is trialing at the moment.   I am a little hesitant in actually recommending it and would therefore merely 'suggest' it would be worth a mention.    We don't know if it is working in Harley's case and won't until we reduce the steroids lower.    This drug is called Melatonin/Cercadin and it is used in the USA for treatment of IMTP  by some Vets.     It is expensive.... around £130 p.m.**  but has no, as yet,  side-effects- though nothing known in relation to long-term use.     We give 6 x 2mg tablets daily (3 x every 12hours) BUT I have to say that he is still on 50mg of Azathioprine as well at the moment and the Preds, hence the reason why we are not sure if they are having an effect or if jointly the drugs are or even if the Preds alone are!!!!    It will be a long time yet before we know if he can stand along with Circadin but my best hope is that Harley can be on as low a dose of Preds as possible by using it..... Might be worth a mention to your Vet.
(P.S.  ** You may be abe to buy it cheaper from the States - I may go that route once we know it is having a positive affect).
Hope this helps.
Gwyneth

Hi
Thank you. I am in the UK. In sunny Kent. I'm trying desperately to resist having to add in another drug. I do have Azathioprine in the cupboard as we did start him on it a couple of months back but he only had one or two doses and in the mean time his platelets went back up so we stopped giving it almost as soon as we started. I really hope that this weeks count is just the usual two week drop and that next week they climb a little. If they drop again next week I'm not sure what to do. I guess we need to see what it is next week and decide then.

That is some very useful information about other drugs. Yes I am in the UK (Gloucestershire). As things are going well with the platelets I thought the preds were doing their job but a friend who has a whippet with auto immune disease gives Atopica which she says has fewer side effects.  I will certainly mention them to my vet as she is, I know, still gathering knowledge about Thrombocytopenia.

Quote from: Whippets Rule on September 08, 2015, 01:37:56 PM
Merlin's platelets have dropped further and are now at 157 no clumps. :( Keeping him on 5mg once per day.

Hi

Please bear in mind that Sighthounds (including Whippets) have a naturally lower platelet count that non Sighthound dogs and as DW says, you may be seeing Merlin's natural platelet level emerging.

Jo

Thank you,yes,I am hoping this is the case. 

Sadly Merlin's platelets have dropped to 96. I don't know what to do now. Am hoping the Vet will text me later with some advice.   :'(

Sorry to hear the count has gone down again.  I hope the vet gets back to you soon. I guess you will have to increase the steroids.

Thank you.
The Vet texted back and is going to talk to someone but has said we can retest his blood on Friday as there was clumping so 96 is minimum value.

Hi

I can see that you don't want a knee jerk reaction but also you don't want it to go down too low before making the decision to increase the preds back to a high dose.  Merlin has had so much going on that it is likely his IMTP has been triggered again.

DW's dog, Harley, has done so well since being on Melatonin, I really think you should give it serious consideration to use alongside the preds.  You have nothing to lose and side effects don't seem to be a problem.



Fingers crossed

Jo

Thank you. The Vet only works a few days a week so won't be at work again until tomorrow at which point I guess she will contact someone for further advice. Since she told me there was clumping and didn't state that it was some small clumps as previously,there is a chance his count could be a fair bit higher. I am inclined to try and remain calm and retest as normal next Monday but will see what options the Vet suggests at this stage. If anything I feel somewhat inclined to go back to 5mg twice per day,stay on that dose until we get stability and reduce again but at a much slower rate ie not keep reducing pred every third/fourth week. In some ways it feels like we have tried to rush the more recent reductions and he only did three weeks on 7.5mg per day which I feel was a mistake.

I've heard back from the Vet and she has consulted soemone with regard to Merlin's dropping platelet count. The consensus of opinion is to continue until Monday on current dose(however I am going to change back to twice daily dosage so instead of 5mg once a day,2.5mg twice per day)then redo his bloods. If his platelets have fallen again,we go back to a dose of 10mg twice per day and regain stability and good numbers of platelets and restart the reduction,slower and in smaller increments. The feeling is that he has done so well thus far on just steroids that getting his dose back up and taking a more cautious rate of reduction could give us better results.

If platelets are better or no lower then we stay on current dose and monitor,only going back to a high dose if we get any further drop in count.

My gut feeling is that we reduced too quickly a few weeks ago and have tried to reduce every third or fourth week,where we should probably be looking at six weeks on a given dose to ensure we get at least two consecutive weeks with a stable count. I also think it was probably a mistake to go to a single daily dose rather than twice daily. Looking back,I remember at the start of Merlin's journey the single daily dose given in the morning only seemed to create instability and his platelets were all over the place but once we went to twice daily dosing we seemed to see better progress.

I really am against adding another drug at this point as for me it will be a last resort. I have to remain as positive as possible and whilst Merlin's weight gain on steroids is a consideration,he hasn't faired too badly in terms of side effects from the pred so going back to a high dose isn't the end of the world,if we have to do it.

I just hope that somehow he has a better platelet count next week and we don't have to revert back again.

Hi

When a dog is on high doses of steroids splitting the dose and giving it twice a day is better because the dog is more able to cope with the side effects. 

When a dog is on a low dose of preds it is more beneficial to give it in one dose before 8-9am, with or just after breakfast, because that is when the body's own cortisol would naturally be produced and more effect will be gained from the amount given.

fingers crossed.

Jo

Is it possible I am giving the dose too early then? I leave for work at 5.30am so have been giving his pred at 5 just after his breakfast.

No, because it has to fit in with your work,  and probably the benefit of giving a low dose all in one go in the morning, rather than giving half of it in the evening, will outweigh the early dose.

Jo

Very sad to report that Merlin's platelets are at 22( no clumps). He's just had zantac so in an hour he goes back to 12.5mg pred twice a day.

The Vet thinks that maybe we will not be able to get Merlin on lower dose than 7.5mg a day. When he was on that dose (5mg in morning and 2.5 at night) he was doing ok.

Can't describe how sad this feels. Poor little dog doesn't deserve this........

I am so sorry to hear this news, and of course you are very disappointed, but you know the treatment worked before and it should work again, so try to be positive.  You are very quick to respond and that is a big plus.

Think about introducing Melatonin.  I see no good reason not to add it to Merlin's protocol.  Are you considering Azathioprine too?

Merlin isn't aware of his low platelet count so thankfully he doesn't have the worry - unfortunately you do, but be positive for him. 

I truly sympathise, and I know what you are going through, but you have to believe that this time next week you will see an increase in the numbers, and you will know that he is on the mend again.

Jo

Quote from: Jo CIMDA on September 22, 2015, 04:37:22 PM
I am so sorry to hear this news, and of course you are very disappointed, but you know the treatment worked before and it should work again, so try to be positive.  You are very quick to respond and that is a big plus.

Think about introducing Melatonin.  I see no good reason not to add it to Merlin's protocol.  Are you considering Azathioprine too?

Merlin isn't aware of his low platelet count so thankfully he doesn't have the worry - unfortunately you do, but be positive for him. 

I truly sympathise, and I know what you are going through, but you have to believe that this time next week you will see an increase in the numbers, and you will know that he is on the mend again.

Jo

Thank you. I have spoken to the Vet but at the moment don't want to add another drug. We're going to try the pred again with a slower reduction and longer on each dosage. If we add another drug later on it will be Azathioprine as there is plenty of knowledge about side effects etc and I'd rather go with something where there is plenty of data etc. If Merlin's toe had been healed and the whole thing amputated at least we would just be worrying about platelets but the toe is a real problem because he is uncomfortable with it. The other negative is that I have to get up at 3 am every day again in order to give him his zantac early enough before his pred dose as I leave for work just before 5.30 am. Doing that for weeks on end does take its toll but I have no choice. My life is on its head at the moment with all manner of changes at work and having worries at home just make everything a bit more complicated but I've been through worse,it just came as a shock that his platelets are so low again and starting back at the beginning is sad. I will admit I don't really expect things to be much different this time around and we will likely get back down to the same dose and have the same problem so I am wondering what's the point but the Vet seemed to think that was the way forward.
Thank you again, I do appreciate the advice very much even if sometimes my text doesn't appear to translate that way. I tend to always sound cross when I post LOL.

I do have some questions regarding dosage ..

Last time round we had Merlin on twice daily dose 12.5mg then 10mg then 7.5mg and then 5mg and then 2.5mg. So at each reduction we were dropping 5mg from the daily dose. Is it possible to reduce in smaller increments for example do a few weeks on 12.5 twice daily then reduce the daily dose by only 2.5mg and perhaps give 12.5 in the morning and 10 at night and then after a few weeks and stability go down another 2.5 to 10mg twice a day? I hope that makes sense. I'm just thinking dropping the daily dose by 5mg at each reduction may have been too much. I'm certain he wasn't on each dose long enough and the Vet was too keen to reduce at the start even though Merlin was tolerating the steroids pretty well.

You certainly can drop it that slowly for sure.

Please don't worry about sounding cross.  Firstly I don't think you do sound cross and secondly we all totally understand the amount of stress and worry you are under xxx

Hi

I am reducing by only .5mg each month and ONLY if I feel it appropriate  i.e. the platelet count tells me it's o.k. to do so.
He is on 5mg at the moment and without sounding pessimistic,  every time we have reached this point in the past, things go wrong.
I will say though, that IF his count tomorrow is static, I need to reduce because I have no other way of knowing what effect the Circadin is having
but I may decide to keep him on 5mg for a further period and/or reduce to 4.5mg daily,

A lady that goes to hydro with me is taking steroids for another condition obviously but she was on quite high doses and when she gets down to around
7mg, she has to be really careful and reduces as I am, by just .5mg each time and sometimes not at all depending how her tests go.

I am not suggesting this is the way you should do things - just the way we are.

Nothing is going to give me more pleasure than to be able to say to this Group, for the sake of other IMTP patients, that hey, this Circadin is working and the very slow regime we have taken with steroid reduction seems to be the way to go.......I pray.

Quote from: Whippets Rule on September 22, 2015, 07:27:07 PM
I do have some questions regarding dosage ..

Last time round we had Merlin on twice daily dose 12.5mg then 10mg then 7.5mg and then 5mg and then 2.5mg. So at each reduction we were dropping 5mg from the daily dose. Is it possible to reduce in smaller increments for example do a few weeks on 12.5 twice daily then reduce the daily dose by only 2.5mg and perhaps give 12.5 in the morning and 10 at night and then after a few weeks and stability go down another 2.5 to 10mg twice a day? I hope that makes sense. I'm just thinking dropping the daily dose by 5mg at each reduction may have been too much. I'm certain he wasn't on each dose long enough and the Vet was too keen to reduce at the start even though Merlin was tolerating the steroids pretty well.

Hi

The previous reducing protocol you describe isn't too much of a reduction, but I don't know the duration.  It is best sometimes to remain on the higher dose for longer for say, 21-28 days,  BUT that is only if the dog can cope with the side effects of the preds. It will be the side effects that dictate the dose and duration of treatment. 

When the daily dose has been reduced - perhaps to 0.5mg/kg/12hrs then you can think about making smaller reductions and for longer periods.  You really do have to base the reductions on how the dog is coping with the side effects. If Merlin is doing OK after the first 14 days then perhaps you can push that dose further to 16, 18 or 21+ days, monitoring how he is coping and then decide when to lower the dose and by how much; and continue to monitor like this at each stage.

When you get down to very low doses of preds then the dose can be reduced extremely slowly and for a much longer duration.

Jo

Thank you.
One thing is really surprising,given Merlin's low platelets,there isn't a single bruise on him! His gums are a little pale but no indication anywhere of any bleeding. His urine etc is normal as well. I am amazed given the count of 22.

It sometimes happens like that

Jo

Six days since we went back to the starting dose of 12.5mg twice daily and his platelets are back up to 151 with no abnormal white cells and no abnormal morphology,whatever that means LOL.

That's great news.  You know he responds to the preds.  I would consider putting him on Azathioprine in the hope that you can reduce the preds after 14-21 days and have a back up this time around.

Jo

Very worried this morning. Woken to find that Merlin is bleeding through his skin in patches all over his body. He is also doing jet black poo (i know this indicates old blood, so likely bleeding high in his gut)which has some red blood on it as well. I can only assume his platelets are no longer 155.  :(

I am so sorry to read this.  Your assumption is more than likely correct and a blood count will confirm this.  Is he on 1mg/kg/12hrs pred?  Your vet may increase this amount to suppress the immune system further.  Also, don't rule out the use of Vincristine if his platelets are very low.

He may also be anaemic through loss of blood.  If his red blood cells are low then find out if the anaemia is regenerative (within the circulation of the blood probably due to a bleed) or non-regenerative (within the bone marrow which will diagnose Evan's syndrome)

Good luck at the vets.

Jo

Yes 1mg per kg. He's on 12.5mg twice daily and he weighs around 12kg's.

Vet said to hold onto our hats. They don't want to increase pred due to the current gut bleeding. Adding azathioprine but as you know this takes a long time to work. The Vet said something I don't understand about the Aza being added to pred and that the pred would increase the toxicity of the Aza.

Basically I have to watch him,if he goes flat it's time to pts. Plasma transfusion has been ruled out as he is highly likely to destroy new platelets faster than they will have any benefit and the stress of the trip to London and the whole process is likely to be detrimental in itself.

 Why won't the vet try Vincristine? 

Vincristine - Azathioprine - mycophenolate etc... What have you got to lose if you are going to pts?

Jo

I don't know and I'm too stressed and too confused to know. I didn't expect to be in this position,it didnt occur to me that his platelets would suddenly drop sharply enough for him to not only bruise but to have blood seeping through his skin and to have his feet swelling up with blood and be bleeding from everywhere. I don't always ask the right questions or in the right way and its not easy to think clearly and objectively when your little dog may be dying. I'm sorry.Merlin is still with us at the moment and not being put to sleep unless I feel he is suffering and is seeing the vet again tomorrow afternoon assuming nothing worse happens in the meantime.

My thoughts are with you but, don't let the vet's action leave you with regrets because you don't deserve that. 

Don't allow the vet's reluctance  to try other drugs, in an attempt to save Merlin, leave you with a lifetime of doubt and regret.

If you agree that their decision is best then that's fine but if you have any doubts, what have you got to lose by trying Vincristine? It might just work and if it doesn't then you have lost nothing and you at least know you tried everything and won't have any regrets.

I hope you see an improvement in him today.

Jo

I have spoken at length with my Vet today and she is going to phone the Royal College and talk to someone tomorrow regarding Vincristine  but Merlin is staying on Azathioprine and Pred and depending upon todays bloods,we may increase the pred tomorrow.
I don't want to do too much with the pred due to his gut bleeding. This is also a consideration with Vincristine because it can have some hideous side effects, one of which is gut damage so I won't use it unless its a worst case scenario situation or unless the Royal College say it's the best way forward.

Merlin has more bruises today but there is currently no blood seeping through his skin,no blood in his eyes and his gums aren't bleeding. He also isn't coughing although he is breathing relatively fast and his heart rate is a little fast. Two of his feet are black but only his toe stump is still swollen, the other swelling from bleeds has subsided. He is no worse but he still has a lot of blood in his poo.

I will never have regrets about the treatment I allow my boy to have or not have,I can only make what I feel is the right decision for him at any given time and it isn't ever as simple as thinking what if or if only, after the fact. I can't make rash decisions or knee jerk reactions and whilst time may be short, in terms of decision making window, I still have to consider the impact of treatment. In the case of Vincristine,it could equally help him considerably or cause his demise and it's not something I can decide alone and seemingly my Vet doesn't know enough about its use(other than for cancer treatment)either so I can't just rush in and give it to him without further information.

Hi

Of course it has to be a joint decision and your vet is doing the right thing by consulting with others. 

For your information I am copying a short extract from a paper entitled:  Immunomodulatory Drugs and their Application to the management of Canine Immune-mediated Disease by N.T. Whitley and M. J Day First published online 26 Jan 2011.  Copyright:  British Small Animal Veterinary Association.

Immune mediated thrombocytopenia
Therapy:

"The only drugs evaluated prospectively in a controlled manner for management of IMTP are Vincristine and IVIG.  Efficacy of vincristine in the management of canine IMTP, either as a sole agent or in combination with glucocorticoids, was first suggested by Greene and others (1982) based on a small case series. Latterly, vincristine has been regarded as adjunctive therapy for stimulating platelet production.  In this capacity, vincristine therapy for IMTP has been evaluated in a small prospective non-randomised unmasked study (Rozanski and others 2002).  Dogs that received a single dose of vincristine in addition to glucocorticoid therapy had significantly faster rise in platelet count and shorter hospitalisation times compared with dogs treated with glucocorticoids alone.  Dogs that received vincristine 7 days after prednisolone therapy was initiated and had failed to elevate platelet count also appeared to respond.  Side effects from vincristine were uncommon and adequate platelet function was suggested by absence of haemorrhage in all dogs once platelet numbers had increased to >40x10 (to the power of 9)/1."


Michael J Day is based at Bristol Vet School, and his profile is so high your vet will know of him.  It might be worth a call to him at Bristol or even an email.  In my experience Prof Day answers very quickly and I am sure he will respond to an enquiry from a vet. It might be worth a try.

Fingers crossed.

Jo

Thank you. My Vet did text me this evening and said that whilst the Vincristine will increase platelet production they arent necessarily fully functioning platelets and therefore the benefits gained could be minimal and the risks can be potentially serious so it's something to consider but probably only if its a life or death situation. I think yesterday we were very very close to the edge but the vets have to order in the Vincristine so it wasnt to hand anyway.
As gross as this sounds,Merlin's poo tonight was much less black and bloody so perhaps indicating that the internal bleed is slowing down. He's covered in tiny bruises but when blood was taken tonight there was no swelling or bleeding afterwards. The vet still thinks this whole episode is a result of the reduction of pred and that last weeks 151 count was a fluke and the low platelets this week more like what we had back in April at the start of all this ie several weeks if fluctuation and very low counts.
He's very thirsty today and his appetite is enormous.
I'm going to have full bloods done in 3 weeks,assuming he improves, to see what effect the Aza is having especually on hisliver and will obviously have to monitor periodically for liver damage.
I know nothing about Azathioprine and asked for it based on your advice so I will need guidance in terms of dosages, assuming he won't stay on 25mg per day indefinitely?

Hi

It is good that Merlin is drinking and eating loads.  It is more worrying when they go off their food.  I have known numerous dogs to have Aza and out of those no more than a few have been taken off it for one reason or another. It is not going to suit every dog, but be positive.  The liver can cope with a bashing and the pred alone can do that for sure.  The liver regenerates when the drugs are stopped or significantly lowered, so don't worry about the long term.  It is more important to get him over this crisis and deal with the liver aspect later.  Many of us here have successfully used Aza as a combination therapy.

The recent quote I posted, regarding treatment with Vincristine, makes this drug option reasonable.  There is no free lunch with potent drugs but usually the side effects are a trade off and worth trying especially if the only other option is pts.

The Aza is given to support the pred treatment and when Merlin is stable and the preds are gradually and successfully lowered then you can start to reduce the Aza, usually going to every other day and then every third day.  I will probably take 6-12 months to wean him off, or he may stay on it forever, but that may be an every other day dose or even every 3rd or 4th day etc.  I don't know if your vet has told you but you don't split Aza tablets or touch them without gloves.

All fingers crossed

Jo

Thank you very much for the info,my next question was going to be about the Aza and dosage etc so you've already answered that one.

No I wasn't told not to touch the Aza, so I'll make sure I don't do that again.

Today there appear to be no fresh bruises,although I haven't yet looked under the dressing on his paw. His poo looked a bit better this morning ie returning to a more normal colour,much less black.

I was wondering if this sudden acute crisis could have been caused by him falling over on Saturday. I know that's probably implausible but he had peed on the floor at some point unbeknown to me and then a bit later ran round the hall and skidded over and landed quite badly which is the point at which I discovered the puddle,when I heard him go flying. He didn't seem injured but he was a bit quiet for an hour afterwards. It's probably highly unlikely but it's almost like he's had 48hrs of complete meltdown but looks considerably less bloody and bruised this afternoon.

Thank you again for the support,this forum is a real lifeline when you're going through this and this weekend has been really stressful. I honestly didn't expect Merlin to be alive today.

Merlin's platelet count is 7 no clumping. :( :( But at the moment there is no further bleeding or bruising and his poo is still less bloody. Right now we are just living on hope.

Oh dear.  7 is extremely low and I fear he needs supportive treatment to see him through until his own platelets are produced. 

If I remember correctly he was slow to respond the first time around and it is likely this time will be the same, so supportive treatment in the form of a platelet, or whole blood transfusion or Vincristine might just get him over this crisis.  I think you have to chuck what you can at him now.

Even more fingers crossed for Merlin - and I know how stressful this is for you too.

Jo

Thank you. First time around we had zero,13,zero,18 etc. I was asked,if I wanted to take him in tonight but have declined and kept him at home. I have also elected not to have the plasma transfusion as at best it might buy him a few hours but he is more likely to destroy any platelets received before they do much good and we feel that the stress of the transfusion etc could be too much. He is here at home,he's happy and comfortable and we have hope.
I spoke to my Vet and we did discuss increasing pred to 2mg/kg but again I have declined due to the amount of internal bleeding yesterday. He is not bleeding at all today and his poo is now perfectly normal. He's still been stealing food and sticking his nose in our cups of tea.
I know how seriously ill he is but he is either meant to be ok or he's not and for once I am doing what I think is right for my dog and knowing him as I do, I know that throwing everything but the kitchen sink at him,will be more stress than he can deal with at the moment and the more stressed he gets the more inclined he is to bleed. Whatever the outcome I will have no regrets about my decisions today.

I do hope Merlin continues to improve today.  Having no regrets is so important and I am sure he will be happier to stay with you rather than go in to hospital.

All the best.

Jo

How is Merlin doing today ? I hope for everything good that is possible for your boy. These disease are so very hard to deal with. I am so glad Jo has been supporting you throughout this time. She is a treasure.

Pam

Just checking in to see how Merlin is doing today.  What a tough time you're having, thinking of you x

Thank you for asking after him. I have been reluctant to post,in case I put a hex on things.

He is still with us and doing ok ish. We know he is not himself but there is currently no visible bleeding at all. He remains greedy and he is occasionally running  about and very waggy tailed. I do understand none of that means very much with this condition but if he was very flat or there were other symptoms I would be even more worried than I am. I also know that he's not supposed to be running about but he would be hysterical with distress if we crated him and I would rather he skipped about than got all stressed and shrieky in a cage.

I have to pin my hopes on his strength and will to survive because unless to some degree his body wants to fight this it ultimately won't matter what we throw at him,he won't have the strength to get through it. That may seem strange to some people and I know sometimes if you throw enough medicine at him,it could pull him through it but in the end he needs to have some ability to fight within himself. I hope having Azathioprine on board will give him some advantage and that it won't be detrimental but I could only make the decision based on what I was faced with at the time and even with all the advice, it still comes down to trying to make the right decision for your dog at a very stressful time.

Thank you again for asking after him, it's really nice to know that people care.

Hello Merlin@s Mum

I am so pleased to hear that, at least, Merlin hasn't deteriorated - and that is such a positive.

I felt I had to write and say just one more thing.....I know exactly how you feel about the body putting up a fight itself and the reluctance (or rather concerns) about giving supplementary medication and sometimes, just sometimes, our gut feelings are soooooo  right.    I remember putting up such an anti, a way back in Harley's illness, about putting him on Atopica.    I know that this drug has worked so well for a lot of people but I personally, did not want him on it.   It had been suggested many many times when all else was failing and he was very ill but still, I looked at alternatives until one day, there didn't seem to be anything left and Atopica was all we had to  try at the time.
So, Harley was put on to Atopica and he was on it for several weeks and my worse fears happened,  the platelets dropped to an all-time low.......God did I reproach myself, I hated myself for agreeing to it but realistically, what I was doing, was hanging on in there with all the hope I could and giving him every chanceI could to live,
so I do know how you feel, really   BUT...
Harley I knew was enjoying life and I just know that he wasn't ready to give up yet.   I had a friend that suggested the kindest thing to do was to have him PTS but I knew we weren't there yet....just as you are.
So, having known that at the start when diagnosed, my own Vet had put him on Azathioprine with the Preds and they seemed to work,  we used them again and they, along with going back to the I.S. dose of Preds again, we managed to lift the count again.   This is now out 3rd attempt of trying to achieve remission and again, he is on 50mg Azathioprine with his lowering Preds and I am scared beyong belief to say this but he 'seems' to be coping o.k.
The Azathioprine stabilised and allowed us to very very slowly reduce the Preds...Aza's were a greatly needed support but still we had to reduce the Preds with caution.
Last year, it was suggested we might give Melatonin a try and again, I was faced with giving another drug to him but these, seem to have little-known side-effects, though long-term, we just won't know.   He is still on the Azathioprine and at some point we will look to reduce them too.
Try not to think about what the drugs may or may not do......if they work and turn him around, yes, they may may, shorten his life (or not) but I'm sure that is a small price to pay.....

Gwyneth

Thank you. I can accept a shortened life but he's just four years old and I want a few more happy years yet :).

Even if he has to stay on a low dose of drugs,whatever they may be,I will settle for that but I know that this time around it is a miracle that he is still here and I don't think he would survive such a close call again. On Sunday he was potentially bleeding out and it was extremely upsetting to watch bits of him swelling up and to see blood seeping through his skin but a little dog with the strength to survive that deserves a chance which is why I have put him on Aza even though it's something I didn't really want to do.

I don't think him or I can go through another episode like last weekend though and I will be insisting my Vet is much more cautious about the pred reduction this time,especially when we get down to 7.5mg per day as that is the point at which they were in too much of a hurry to reduce further and I feel he needed several weeks of good platelets before we reduced.

He is currently on 25mg per day of Aza and 12.5mg twice a day of pred. I am still very worried as I know he's not quite himself ( I can't really explain in what way but something doesn't "feel" quite right about his behaviour today)and some blood vessels seem to be really standing out on his body which worry me. I am very scared for him because as an owner I make a pledge to love,care for and protect them and this illness leaves me helpless and unable to fulfil that promise. If hope that keeping him as quiet as possible,keeping everything as happy and normal as possible and just sheer force of love and kindness will help him have the strength to survive. If it doesn't, then he is simply not meant to be and that's something no one can fight.

I hope so very hard this is a turning point in Merlin's life and that he starts to steadily improve. I have lost too many dogs over the years, some much younger than Merlin, so I know just how hard it is to see a special friend struggling.

Please keep us updated

Pam

Hi

Merlin's just a year younger than Harley and I totally agree, though these horrid diseases are shocking for any dog, whatever age, it seems so much more unfair when they are our ages, as they haven't yet had a life.  Harley's had this since he was 18 months.

You really have had such worrying times with merlin and my heart goes out to you and how you are feeling.....wish I had a magic wand for all of our dogs that are so poorly.

Fingers crossed though, that this has been a set back, a horrible one but a set back and that he (and you) have the strength to continue with some optimisim...hard as it is.

Give Merlin a big cuddle from me.

Gwyneth

Merlin's platelets are 517 today. Should I be worried? Can you have too many platelets? We are going to reduce pred to 10mg twice a day next week IF platelets are still very high. Does this very high count mean that the Aza is starting to work?
This raises so many questions for me. Merlin has had a small amount of fresh blood in his poo which is a worry as it maybe he has an ulcer?

Hi

Yes you can have too many platelets and this is known as thrombocytosis. It is likely to be a reactive response to the steroids.

When the platelets are high there is a risk of blood clots and ironically a low, anti-thrombotic dose of Aspirin is often given. What is his red blood cell count like? How is he in himself?

To increase from 7 to 517 in one week is very unusual but it does prove that is bone marrow is producing.

What does your vet say about this?

Jo

Vet only texted me the result but made no comment even when I asked if this was too many.

She just said yes to reducing pred next week if still high. I have done some reading around the internet and it's possible it could be a reaction to the amount of bleeding last weekend? and a reaction to the drugs,possibly everything going into overdrive? I am more concerned than ever as I definitely wasn't expecting this as a result. Is it possible that the Azathioprine is working already or maybe causing some kind of reaction?
In himself he seems perfectly normal,active and waggy tailed and a greedy pig.

I think maybe a full blood count is due after this result. He is back at the Vet's next Monday so I will ask for full bloods to be done.

I've just texted the Vet again and she is getting the practise to ring Idexx and extend the blood test to include all the other cells etc as it is such a massive jump in platelet count. We should have further results tomorrow.

Hi

No, it wouldn't be the Aza, if anything Aza will suppress bone marrow production.  It is typical of a steroid response but to reach this number so quickly is unusual.  It could be that last week's result wasn't accurate and it might have been higher which could give a false, marked increase in platelets.  Also, one would expect a response from the bone marrow after 5 days of starting immunosuppressive therapy, but Merlin's response seemed to be slow (if I remember correctly) so perhaps the pred had finally kicked the bone marrow into action and it then went bananas!!!

Try to see this as a good result, but it doesn't really want to get any higher.  There are other reasons for thrombocytosis but I think you have to assume it is the preds - and what you say is true when the body is deficient in something it can respond by going into overdrive.  This is quite normal though. 

It is good that he is greedy and waggy tailed.

Jo

Hi - Luca had IMT before she developed her current immune issues, she was treated with pred, cyclosporine and melatonin, platelet count was zero for the first 8 days and she needed transfusion as she bled out half her blood volume into her intestines. She also had vincristine.

She started to improve on day 9 (20) and was having daily bloods until day 11 when I took her home with a count of around 120. A blood test at the vets 2 days later had a count of 1,400 !!!!!

The specialist said it was not unusual to get a thrombocytosis when they start to respond but would only worry if they continued to rise - her count gradually reduced over the next few weeks to around 300 where it has stayed ever since.

He didn't want to give her aspirin.
Hope this reassures you a bit .

She came off the pred and cyclosporin and was just maintained on melatonin.

She didn't tolerate pred very well so when her newer issues started we have just managed them with cyclosporine plus she's still on melatonin.

Thank you very much, that does help a bit,he had a lot of bleeding in his intestines during last weekend.

Just heard back from the Vet and apparently nothing major to worry about at the moment. White cells were I think down? something about inflammatory response and we think that's to do with his paw and the pressure sores etc.

The only thing I am questioning is that the Vet spoke to a specialist at Idexx and they have said that it could be his body responding to the bleeding from last week and the Azathioprine and pred combo already kicking in. The specialist said to only keep him on the daily Azathioprine for  a month and then move to an every other day dose because he was doing so well on just steroids alone without any side effects. We're not to change steroid dose or anything for at least two weeks as there is a chance this was just a spike due to response by his body and from the drug combo and that things will level off to a lower more true count in the next week or so.

I did say to my Vet that I understood it to be keep them on Aza and reduce pred first and she said that's what she thought but the Idexx Specialist said no because he was responding really well to just pred so he probably doesn't really need the Aza.

Your thoughts would be welcome. Thank you.

Hi

I don't think you can make any plans regarding treatment regime at this stage.  Wait and see and make these decisions at the time depending on how Merlin is in himself and the blood results.

Jo

Today Merlin's toe stump is all ulcerated and he has pressure sores both sides of his paw and up around his wrist he has sores opening up. I don't know why this has started to happen but I have put him back on antibiotics today and will need to get some more from the vet tomorrow.

Is there anything I can do to help with the sores other than bathing in salt water etc. He cannot walk around without a dressing on his foot or the toe stump breaks open so I have created a dressing which covers his toes and is taped to his leg below his wrist so that all the sores are uncovered apart from obviously his stump. He has to have a cone of shame on or he will just keep trying to lick.

Sadly he is not going to be able to be walked again until such time as he can have his toe stump amputated which is likely to be months away.
I am feeling very sorry for him and very frustrated because if his toe had been properly removed in the first place, all we would be dealing with is his platelet issues and not a horribly ulcerated foot. I have also found today that he has some hair loss and a "swelling" on his other wrist. I sincerely hope the "swelling" is just a fatty lump and nothing sinister.

Hi

You could try Manuka honey dressings.  Manuka honey dressings are used more and more these days in conventional medicine, both human and veterinary,  with good effect.  It is worth a try.  Also an alternative might be to use aloe vera gel but you have to put this on about 6 times a day. 

I hope the swelling reduces very soon.


Jo

Merlin is not well today. The sores around his wrist look infected and keep breaking open. THe lump on his right wrist looks sort of purple and white under the skin and he has thick green pus coming out of his eyes. It's as though overnight everything has started to go wrong. It seems like infection gets bad very quickly when they are immuno-suppressed.

Hi

If he isn't on two different antibiotics then I would ask your vet for them.  He needs help to fight this infection and by giving two different antibiotics you have a chance of addressing the infection. 

Also think about reducing the preds now. You have to read a situation at the time and act accordingly and not hang on to whatever plan was made last week. 

Good luck

Jo

I wish I'd seen your reply before I went to the Vets. He's only on one antibiotic which is Therios Tablets twice a day. He has Isathal for his eye infection. The lump on his right wrist has not been identified and could just be injury somehow but the Vet said regardless of what it is we cannot do anything to him at the moment due to the Aza and Steroids. I will see how he goes over the next few days and if no improvement I will ask for different antibiotics.

Hi

If you are lucky the one type of antibiotic might be correct for whatever bacteria is present, but if there is a need to address the infection quickly then two different types will address most (although not all) bacteria. It saves valuable time in waiting to see if the first antibiotic works. This is not an uncommon method of action, in veterinary and human medicine, when a bad infection is present.

I wonder if the swelling is his body reacting to chronic infection/inflammatory disease.

Jo

Finally got Merlin's platelets for this week and they are 394 with small clumps.

That's a good result.  When will you reduce the steroids?

Jo

The specialist at Idexx said after two weeks,which will be next week. Provided next weeks count is good I will reduce to 10mg twice a day. According to the specialist i should change to every other day with the Aza after one month so hasically 3 weeks time but I am unsure because despite them saying he was doing well on steroids alone,we still didnt establish good stability. I think we need to take it a week at a time and see.

Platelets from yesterday 351 with small clumps so I am reducing Pred from 12.5mg twice daily to 10mg twice daily. I'm wanting to reduce as his heart rate is fairly high and I have noticed that this has been the case for the past week and I suspect it could be the steroids. Also respiration is faster than normal so any small reduction will hopefully help. we're going to leave Aza as it is for another two weeks and depending on count at that stage the Vet wants us to go to every other day dose of Aza as recommended by Idexx. Sadly I don't know enough to argue one way or the other with regard to Aza.

That's good news for Merlin.

Jo

That sounds very reasonable to me. I remember with Saffy's reductions we only ever reduced Pred on it's own, or Aza on it's own, never at the same time. And we gave 2 weeks or more in between each reduction.

 :( Real set back today,Merlin is off to the Vets shortly as it looks like he has a blood clot in his leg. The swelling on his wrist has doubled in size and turned more purple during a short walk. He has a "contusion" below the swelling which is where I believe the clot has formed. I am extremely worried at the moment. I am wondering if it is worth changing him to an every other day dose of Azathioprine immediately in case this is keeping his platelets too high?
Help!!!

Back from vets.Merlin does have a blood clot. He has a pressure bandage for the next 3 days and we have to keep him quiet but vet said dont alter aza as we have only just reduced pred and we need to see what impact that has first. Since we've been home,he has a small bleed on top of the foot which has the clot at the wrist. Am v worried tonight.

since having the pressure bandage put on last night,Merlin has developed a second blood clot. The one with the pressure bandage is at his wrist but the second clot is at his elbow. I don't know whether to keep the pressure bandage on or whether it would be better to take it off.
I no longer know what to do.

It will be the pred that is more likely to be causing blood clots.  How about low dose aspirin?  Have you recently checked his platelets?

"To decrease platelet aggregation/Antithromobtic dose and adjunctive therapy with Azathioprine and glucocorticoids for Immune mediated disease:  0.5mg/kg once a day". (Plumb's veterinary Drug Handbook)

Ask your vet if it is better to take off the bandage.

Jo

I had to call the emergency vet and was advised to remove the bamdage for a spell amd see if the wrist swelling increased. It did and my options were to bandage the whole leg or just the elbow clot. I habe opted for whole leg. He's not happy tonight but he's ok. We reduced pred on Tuesday to 10mg twice a day. He is due a platelet count again on Monday. Is it worth reducing pred again this week if platelets are still high?

Yes I would think so. 
How is he today? what a terrible time you're having, I'm so sorry for you.

He's quite flat today but he has perked up a little this afternoon. I changed the full length pressure bandage this morning for another full leg one but when I changed it the swelling on his wrist seemed to grow in size. The blood that had dispersed up his leg with the original pressure bandage,has faded a bit which is a good sign I hope and the clot at his elbow is marginally smaller. I'm not sure what to do tomorrow as he has to have the bandage off then. Hopefully tomorrow the vet will have some suggestions. I have decided to leave the Aza as it is for now and concentrate on reducing pred until we get a mid range count and either resolution of the clots or at least a situation where they are no bigger. I am quite worried at the moment that some of these issues are the beginning of the end for Merlin but I hope with all my heart that they are a short term complication and nothing more. His heart rate is still up and respiration still high but its hard to tell if this is drug induced or because he is uincomfortable.

Been back to the Vets and blood has been taken. I had removed the pressure bandage so the vet could see his leg but the swelling at his wrist joint has doubled in size since then. The Vet is ringing the lab again to discuss the swellings/clots and what we need to do next in terms of drug adjustments. Hopefully she is going to call me later and let me know what the score is with that and then I can ask her about the increase in the swelling.

Well the vet never did ring back but she's on holiday now so a different vet rang me with Merlin's platelet count. 352 no clumps.
This Vet said she was ringing the lab to talk to a blood specialist so we have a plan in place for next week. At the moment because Merlin usually has a big drop in platelets the second week after a pred reduction, we are leaving everything as is for a week. When we get next weeks bloods the Vet will have the plan in place(once the specialist decides)so that we know whether to reduce pred again or to alter the Aza next.

My biggest worry currently is the swelling at his elbow and at his wrist. They are supposedly blood clots and obviously there was a lot of blood under the skin but the swelling at his wrist has been there a month now which seems odd.

Also,unfortunately today I got home to discover that Merlin had removed the dressing on his bad paw and there is pus coming from one of the pressure sores,which he has licked to death practically. I had to dash over to the Vets to get yet another course of antibiotics for him. He's back wearing the cone of shame again as he needs to keep the area of the pressure sores uncovered for a few days.

He is a little disaster area at the moment but he's still wagging that skinny tail so we just keep on trying.

I would want the preds reduced before the Aza.  Merlin has been on (and off) high doses of steroids for so long now his body needs to return to some degree of normal function. I believe these issues are more than likely to be due to long term pred use.  The Aza should be established now.

Have you thought about giving him some live yogurt, or pro and pre biotics, to restore some of the good bacteria the antibiotics have killed off in his gut?

Jo

Thank you as always for the advice. I will push for dropping the pred. The Vet I am seeing next Monday is a newer grad and seems really on the ball.

I will get some live yoghurt. I do give the dogs live Goats milk yoghurt occasionally but haven't done so for a while but I'll get some for my little mouse tomorrow. Today the swelling at his wrist does seem marginally smaller.

I am very worried about Merlin today. Both joint swellings/blood clots are large again and the elbow one was bleeding through the skin. I have re-applied a full leg pressure bandage. He also developed a spontaneous bleed in the main pad of his bad paw. A black patch appeared which simply began to bleed. I'm at a point at the moment where I feel that if he has any more setbacks,it might be kinder not to continue but its so hard to say that about my beautiful four year old dog. :'(

I'm sorry things are not improving.  Perhaps you need someone more specialised to have a look at Merlin. 

A full biochemical and complete blood count might be a good idea to look at the bigger picture.  It is natural to assume all problems are due to the autoimmune disease or treatment.  Having said that, what have you got to lose by dropping the preds significantly?  The Aza is well established now and it might just make a difference to all that is going on with his joints and paws.

Good luck today.

Jo

Thank you. We had full bloods run just under 3 weeks ago when the clots etc started and everything else was fine, only white cells were a bit off but vet said this was likely due to inflammatory response due to infection.

I will feel happier when I've spoken to this different vet as she really does seem on the ball. He is a bit sparklier today though so we will keep trying. If I feel the vet isn't up to it I will ask for a referral as I think we have gone far enough without really specialised advice. It's all right getting advice from Idexx but they don't know or see my dog and that makes a heck of a difference when you see him in person and can see how raggedy he looks.

Just a thought.  I wonder if Merlin has cellulitis, possibly as a result of his immune system being suppressed for so long. 

Have you had an aspirate and a culture done of his swollen leg?  Perhaps the antibiotics he is on are not the correct ones for the particular bacteria causing the problem.

I wouldn't worry about his raggedness.  That is to be expected and it will improve when the preds are lowered.

Jo

Not had an aspirate done. The swelling at his elbow is definitely a blood clot and the one at his wrist is unidentified but also has a blood clot. If he walks around without a pressure bandage he starts to bleed under the skin at the wrist swelling and it more than  doubles in size. The rest of the leg is completely normal. I will be happy when the vet sees him on Monday as I have lots of questions for her.

Platelets are 410. Waiting for Vet to call later as she has contacted the RVC and has information from them. She needs to discuss this with my usual vet and put a plan in place,then she will ring me and let me know. I hope this will be beginning of getting Merlin under better control as at the moment I'm feeling a bit let down that 8 months into treatment he's worse not better.

Hi

Take comfort from a platelet count of 410, and also the confidence this result should give - now you can lower the preds. 

Aza has always been such a good combination drug and it is must be assumed that is is working for Merlin.  Over recent years more and more new immunomodulating drugs have been introduced to veterinary medicine and although there is some merit in using new drugs sometimes the tried and tested ones are the best, if only because the response is reliable. 

I would like to see Merlin's preds reduced - not the Aza - so that his body can get back to behaving normally once again.  Preds are amazing and without doubt a life saver.  The knack is to know when to reduce to optimise their benefits.

This is good news.
Jo

Thank you. Reducing pred tomorrow morning to 7.5mg twice a day.

We've just had to rush Merlin to the vets tonight because when I changed his dressing, on his bad paw, the scab had come off exposing the ligaments in his foot. He is even more heavily bandaged,needs daily cleaning with hibiscrub and has some Tramadol for the pain. Poor little sausage really is fed up now.

Oh poor lad.  I'm so pleased you are reducing the preds.

Jo

Aaaaarghhhh..... Platelets at 450 no clumps.... >:( My Vet is now back off holiday and supposed to be contacting the RVC on Thursday morning to discuss what to do with the drugs etc for Merlin. So far I have insisted on altering pred not Aza but the vet has mentioned several times the risk of liver damage with Aza. Merlins last full bloods showed nothing wrong so I kept him on a daily dose of aza. I am keeping him on current dose of 7.5mg of pred twice a day until after next weeks bloods as he usually has a dip in platelets on week two of any reduction.

Hi

So when Merlin's liver enzymes come back significantly raised your vet will assume it is the Aza that's the bad boy - when in reality is is more likely to be the preds (and considering how long Merlin has been on steroids this is to be expected).  On the face of it Aza seems to agree with Merlin and you have to say it looks like it is doing its job.  The liver regenerates remarkably well so I wouldn't be too alarmed if the enzymes are high - it depends how high.

I hope you get the result you want.

Jo

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

Hi

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

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

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

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

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

Jo

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

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

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

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

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

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

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

Jo

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

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

I hope he improves soon.

Jo

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

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

Hi

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

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

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

I really worry about some advice that's given.

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

Jo

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

Jo

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

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

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

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

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

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

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



This is the boy tonight. He has multiple sores and infections in them and infected eyes....
(http://i10.photobucket.com/albums/a115/zookiheap/12278801_10206283273974094_4530384002193975749_n_zpsesbbbvic.jpg)

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

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

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

Some info about Therios

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



He should feel much better soon.

Jo

Hi

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

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

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

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

Hi

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

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

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

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

Jo

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

Merlin seems much much happier today and more lively and sparkly. I think the redcution in pred to 5mg twice daily has made all the difference in terms of how he feels in himself. The antibiotics are managing the infections which is really pleasing as they have worked quickly.
Below is a picture of Merlin's amputated toe which although healed still needs surgery to remove the rest. I still don't understand why the vet left the rest of the toe there. Merlin has to have an entire Soffban padded bandage and half a roll of vetwrap on his paw every day simply to keep him comfortable. He is still unable to go for a walk.
(http://i10.photobucket.com/albums/a115/zookiheap/12309141_10206297331045512_74619307_n_zpslf5lub6w.jpg)

How is Merlin doing now? that toe looks good to me.

Merlin is doing ok in himself and seems pretty happy. I reduced Pred to 5mg in the morning and 2.5mg at night last Thuirsday as his breathing is still not great. The toe looks ok on the top but the end of the stump has broken open again and is all bloody and horrible. The pressure sore one side of his paw looks much better but the other side has also opened up. There is however no infection present and he's not quite finished his antibiotics yet.

We should get a platelet count tomorrow and then one again next week. Next week we have to reduce Azathioprine to an every other day dose and he will remain on that dose and the current dose of Pred until the New Year,in the hope that it gives us a stable and relaxed Christmas. I have been diagnosed with dangerously high blood pressure and with the risk that I have kidney damage already so I need to have a little less to worry about over Christmas. In the New Year we aill then reduce Pred again and then the Aza again and so on. With luck we might even get him in remission.

Hi

Has the stump broken open underneath because of the pressure of walking? If you don't already, perhaps binding it before a walk will protect it and take off any pressure.

I wish you well and hope that Merlin's IMTP stability will give you less stress.  Look after yourself too!

Jo

Merlin has a heavily bandaged and padded paw at all times and is still unable to walk more than 100 yards. Yes it is the underneath of the stump. The vet said it is due to the pred. His platelets are 469 today so provided they are still high next week we will go to every other day dose of aza for probably 3 weeks then reduce pred to 2.5mg twice a day after that.

Hi

I still don't understand why the vet doesn't want to reduce the pred first.  Merlin's platelets are high and he will not heal fully until the preds are lowered, so why not lower the preds?

Jo

Merlin has woken this morning wth infection in both eyes again and a swollen and infected bad paw. He only finished antibiotics last Tuesday and already infection has returned. I have just given him some antibiotics and have enough to get him to his vets appointment on Tuesday but I am still concerned that infection appears so quickly each time we stop antibiotics. I would rather reduce pred again than aza but the vets and the RVC are all adamant that the aza will destroy his liver. If we do reduce aza this week, I will not be reducing it again until I am satisfied that we have reduced pred further before hand and his skin is improving.

Hi

I'm sorry Merlin is having to deal with recurring infections.  It is only the result of a compromised immune system and I hope when the preds are lowered he will not have this problem.

It is must be very exhausting for you.

Jo

Thank you. I've just been signed off sick for a week as my blood pressure is way way too high. I now have to have an ECG in two days in case something more serious is occurring. Obviously the ongoing worrywith Merlin isn't helping. Poor little guys paw is still quite swollen and I will be glad when we've seen the vet tomorrow.

Merlin's platelets are 397 today so we are going ahead with every other day of Aza. The next reduction,assuming all is well, will be pred and after that we will see. The vet suggested that each time we reduce pred from this point on that we reduce to 2.5mg twice a day then 2mg twice a day and then 1mg twice a day so making much smaller reductions. That is all assuming platelets don't crash when we go to every other day on the Aza.

Merlin was well enough to have a good bath and has had no dressings on his legs/paws all day. Tonight I have also left him free of dressings. He sleeps on my bed so i will hear him if he licks his bad paw too much but at the moment it is the most healed it has been. He seems very happy and waggy tailed. He is now on day 4 of EOD dosage of aza.

Hi

So pleased to hear Merlin is improving.  A great Christmas present.

Jo

I haven't checked in for a while (stuff going on at home with my own animals) so it's great to hear little Merlin is doing well.  Good news.

Thank you.

We are on day 7 of EOD Aza and (Merlin has effectively "missed" 3 doses)platelets have gone back up to 460. The slight down side is that he has another blood clot at his wrist, next to the original one, which remains purple and slightly swollen. I am avoiding applying a pressure bandage unless the swelling is significant. Next weeks platelet count will be crucial as it will be two weeks after reducing aza. He remains much happier and I am really hoping that this is the start of getting him in remission.

I hope you all have a fabulous Christmas and that all your dogs remain as stable and well as can be. xx

Best wishes  for the Christmas /New Year  festive season. I hope that Merlin's recovery continues and that 2016 is MUCH less stressful for you and for him.

Thank you.

Today we have 413 platelets. Merlin unfortunately has a hole in his toe stump and we can see inside his toe. It is very inflamed but the pressure sores on the sides of his foot have not re-opened so far although one side it looks very red.

He is on the second ten day course of antibiotics now,having had a break of five days.

Next week if platelets are still good we will reduce Pred to 2.5mg twice daily. After that we will go to every third day on Aza and then all being well, reduce Pred further but only by 1mg from the daily dose. each reduction will be followed by 3 platelet counts to be sure nothing untoward is happening. I am surprised that platelets fluctuate as much as they do but because I don't know what they are like in a healthy dog its difficult to know what is considered normal.

Hi

This is great news.  I feel his skin problems will gradually get better as the preds are lowered.

Jo

Merlin has appeared to be doing well and he's on 2.5mg pred twice daily and eod aza. He's managed a couple of decent walks this week with a heavily bandaged paw. His "blood clot" is still there at his wrist and blood is being drawn from it next Tuesday and being sent to the lab to see if anything sinister is present. Sadly tonight after getting up from a snooze by the fire, Merlin has had a nosebleed. He's not had one before and I am a bit alarmed but his platelets are 378. I think on Tuesday it's time for full bloods to be done again as well just to see what's going on.

Hi

Was the bleed from both nostrils or just one?  As a general guide, a bleed from both nostrils can indicate IMTP.

Hope all goes well on Tuesday.  If he has another nose bleed and it is from both nostrils, then I would take him back sooner to check his platelets.

Jo

Hi platelets were done on Wednesday and were 378, could they have dropped that much to cause bleeding? The bleed looked as though it was both nostrils but it stopped very quickly on its own. I only realised it was happening as I cleared up the food bowls directly after his dinner as his bowl had blood in it. I then saw blood on his leg and remembered he'd been asleep by the fire with his nose resting across his leg. I am going to get them to run any tests necessary on Tuesday as I still have a gut feeling something else is going on as well as the IMTP.

Hi

Platelets can drop quickly but I am not suggesting that it is IMTP, just that it is worth checking again.  I would have expected bruising somewhere if the nose bleed is a result of low platelets.   Could the blood have come from him catching his mouth on something?  An IMTP nose bleed would usually be significant.

Good luck tomorrow.

Jo

Thank you. Was definitely a nosebleed and not his mouth. Full bloods are being run at the lab and should get results tonight or tomorrow. The vet decided not to draw more fluid from his wrist as all she got last time was diluted blood and as his elbow has settled down,she feels his wrist will too.

I wanted full bloods running to see if there is some other issue that Merlin has although eight weeks or so ago his bloods came back normal.

I do have a random question. We are getting a new addition to the family around the end of February,a lurcher pup to join our gang. Are there any special precautions I need to take when vaccinating the puppy,as in minimising any risk to Merlin? We are well prepared in terms of making careful introductions and minimising any stress for Merlin. The vet feels that Merlin is in a good place and hopeful that if not in remission at the end of this treatment,at least able to have his toe sorted and to be maintained on a low dose of drugs. He has improved in leaps and bounds and is so much his old self it's hard to believe he has been as ill as he has.

My AIHA dog was still on medication when we got a puppy (although obviously she was over the worst and had been on the road to recovery for some months). But just to be on the safe side, when our puppy was having vaccinations we had a separate part of the garden for the puppy to urinate and defecate in and did not encourage too much closeness with the AIHA dog for a few days afterwards.

Thank you,that's really helpful to know. I feel confident that adding a new addition won't be too detrimental to Merlin's wellbeing,he is a tremendously tough little guy and despite still being on medication has had good platelet numbers for several weeks and seems to be very much his old self. We're on quite a low dose of pred now and shortly will be going to an every third day dose of Aza and assuming all goes well he will have his toe amputated properly soon.

Platelets are at 373. Haemoglobin and reticulites were high but everything else ok. Two of the liver enzymes were slightly high but only consistent with long term steroid use. Vet was very happy and wants to carry on at same dosages for another two weeks to be sure we have stability then go to every third day of Aza.

That's very good news.  What is is HCT?  Did they say why his retic's are high? He is not on a high dose of steroids anymore.

Jo

I cant remember all that she said but she said something about his body producing loads of new red blood cells. She said something about haematocrit but i forget what. She said there was nothing alarming or worrying. The fluid from his wrist just shows dilute blood although his wrist is still swollen and purple.

I'm wondering if anyone has seen anything like this before...this is Merlin's good leg. It's his wrist where the first "blood clot" was. Its still very lumpy,swollen and purplish looking. The fluid drawn off by the vet was just dilute blood and she examined it under a microscope and said its just blood cells and dilute blood. It's more swollen since fluid was drawn off two weeks ago. He had another purple swelling at his elbow but that one has gone completely. The initial swelling appeared when he went on Aza and had too many platelets....

(http://i10.photobucket.com/albums/a115/zookiheap/8254_10206644865133647_522076116581497549_n_zpsex6l4qsf.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/12507166_10206644865973668_9000124296277499805_n_zpsibwnygan.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/12524293_10206644865293651_726858547977485675_n_zpsdnokqtu7.jpg)

(http://i10.photobucket.com/albums/a115/zookiheap/12524293_10206644865653660_5827635142367317402_n_zps7kns5stw.jpg)

Hi

Too many platelets can cause blood clots and this is why it is not good to let them increase too much above the reference range.

Steroids increase platelet production  and this has to be watched when a dog is on steroid therapy. High platelet numbers can form blood clots anywhere in the body and this can be dangerous, depending on where the clot forms.   A dog recovering from IMTP doesn't want platelets above the reference range.  Once they start to creep up to the high reference range, the steroids should be decreased in an attempt to control their numbers.

Jo

Thank you. He has 373 platelets and the vet wants him to stay on 2.5mg pred and every other day aza for two more weeks rather than changing drug dose now due to precious instability when we reduce. As things stand the vet wants to reduce aza to an every third day dose next and leave pred as it is as she doesn't consider 2.5mg twice daily a high dose. Does this seem right?

I think I will re-apply a pressure bandage.

Hi

Merlin's current drug regime seem fine to me.

Jo

I've taken a chance this week and not had Merlin's platelets done. I was too unwell to drive yesterday as my blood pressure suddenly started dropping too low and today I have to go back into work so it would have been Thursday before his bloods could be done and I decided as drugs are not changing and he's been quite stable I would risk not doing bloods and wait until next Tuesday. We've done weekly platelet counts for 10 months so it's nice for him not to have to go for once. The antibiotics have improved his skin again and I have removed all the dressings and his foot looks pretty good at the minute. His purple wrist still looks nasty and I may resort to a pressure bandage yet again tonight. The past four weeks is about as well and healthy he has been since this all began last April and it's so nice to see him happy even though we still have a long way to go.

That's such an encouraging posting and great to read.

I hope you are feeling much better soon.

Jo

Today we have 364 platelets so now we go to every third day on aza. If this works he will gradually come off the aza over the next couple of months and then we'll bring down the steroids.....if we can.

That's great news.  Things are looking up for Merlin - and you.

Jo

After a week on every third day of aza Merlin actually had 384 platelets. :D

Wow, perhaps you have finally turned the corner.  It can happen like this.
I do hope his skin problems will resolve now.
Great stuff!
Jo

I haven't checked in for a while, and am pleased to see such a positive update for Merlin, how is he doing now?

Merlin is ok but still getting skin infections,still has two nasty blood clots on his good leg which are increasing in size. He also has an open hole in his toe stump. platelets are at 376 and he is on 2.5mg pred twice a day and three quarters of a 25mg aza tablet every third day. I have however made the decision that should this all go pear shaped as we get down the drug levels,I am going to have him put to sleep. He did not cope well at all back on high dose pred and the aza has caused complications with the blood clots. I don't believe it will be in Mwerlin's best interests to put him through this treatment regime yet again and feel it would be kinder to let him go. He has had approx 5 short walks in 10 months...for a running dog that is also a miserable existance.

Just thought I'd update this, just to say that it's highly likely that Merlin will be put to sleep this week. His bad paw keeps swelling up and getting infected, he has multiple blood clots in his good leg and despite still having platelets in the normal range he is still on drugs. Sadly as my divorce is progressing and my husband refuses to pay anything towards Merlin's vet bills I am now faced with either calling it a day for Merlin or not being able to afford to put fuel in my car to get to work. I feel in many respects that ultimately Merlin will not make it and I am simply bringing forward the inevitable but there is also part of me that feels like I am murdering my dog but I have no choice now.

 I have been following your posts since Merlin first became ill. The  poor fellow has been suffering for many months. Not just pain, but   he has been unable to go for walks or to enjoy running free like whippets are born to do.  A miserable existence.  It sounds as if Merlin's suffering will continue no matter how much money you have to spend on vet treatment.  Don't think about it as murder but as setting his spirit free. 

Hi

I am so sorry for your situation.  I don't want to dissuade you, and I know that any decision you make will be out of kindness,  but is there anything I can do to help your situation? 

If Merlin's platelets are within normal limits, why is he still on drugs? What drugs is he on?  If he was off drugs would there be a chance of his skin healing and the blood clots ceasing?  Please don't feel you have to answer these questions, I don't mean to pry, but I have always taken a keen interest in Merlin and it would be awful if you made a decision you might regret without me trying to help if I can.

Sincerely

Jo

Merlin is on 2.5mg pred twice a day and half a 25mg Azathioprine every third day. But to be fair his blood clots are very big and his bad paw is swollen and the pressure sores are back. He can't be walked and he can't have a bandage off his bad paw for more than an hour even indoors as his stump bruises up and swells. Financially, I cannot manage now I have to pay the bill's alone.
Merlin is left with the others during the day as I now work all day and when I get home I have to leave him again to walk the other dogs as he can't go out. He gets hysterical and shrieks when I take them out and leave him. For a southbound a life of no walks must be intolerable. I have been doing this for a year now and it breaks my heart.

I know it sounds drastic, but if the rest of him is okay, is it not viable to have his bad paw amputated?  Can something like a whippet rescue society help out, if only temporary?

Hi

My feeling, based on many experiences, is Merlin's whole skin problem is due to the preds and if these were now weaned down and withdrawn over a week or so, his skin and the blood clots may have a chance healing and resolving.  What have you got to lose?  It will not be an expensive exercise and there is more than a chance his legs will improve and he may be able to live a normal life again - and you will feel so much better about this situation.

Prolonged use of Prednisolone, and other drugs, can have a devastating affect on the skin, and generally if you address any present bacteria and remove the cause it should return to normal.  He is still on Aza and if this keeps his IMTP in remission you are in a win-win situation. You may even be able to wean him off the Aza.  If this approach doesn't work, you have lost nothing. I hope you will give this some thought.

Jo