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Messages - Jo CIMDA

#1
Hi Jenny and welcome

A daily dose of prednisolone is the recommended way to provide a replacement dose of glucocorticoid.  It is usual, when starting treatment for Addison's disease,  for the dose to be on the higher side as this will address the stress that the dog is experiencing at this time of diagnosis, but as the DOCP starts to become effective, and the dose of replacement mineralocorticoid hormone is satisfactory, as long as the clinical signs and the blood results are within normal limits, then the daily dose of prednisolone can be reduced to the lowest replacement dose.  See this reference:

https://todaysveterinarypractice.com/endocrinology/diagnosis-and-management-of-hypoadrenocorticism-in-dogs/

For glucocorticoid replacement, oral prednisone at a starting dose of 0.5 to 1.0 mg/kg/day is usually recommended. This dose should be gradually lowered (over several weeks) to an optimal dose that controls signs of hypoadrenocorticism and avoids side effects (e.g., polyuria, polydipsia, polyphagia, panting). Larger dogs seem to be more sensitive to the side effects of glucocorticoids. Although published maintenance doses are usually 0.1 to 0.22 mg/kg/day,4 we have managed a number of patients with lower doses (as low as 0.03 mg/kg/day). Dosage adjustments should be based on clinical signs only; for dogs with confirmed naturally occurring hypoadrenocorticism, an ACTH stimulation test should not be repeated for monitoring purposes.


I have never known an Addisonian dog to be put on every other day dosing of prednisolone in order to provide sufficient replacement glucocorticoid hormone. The general opinion is that this will not be sufficient because prednisolone has a biological 'half life' of 12-36 hours, so a daily dose is required.

Personally, I would always carry a little extra prednisolone when out on walks etc., because if Yanka becomes stressed for whatever reason (her body is unable to produce the required increase in glucocorticoid to combat the stress) then you will have the extra prednisolone to hand. This extra dose doesn't need to be continued after the event is over, it will do no harm, and it will support her through the stressful event, so you can resume with usual daily dose of prednisolone the following day.

It can take a few months to establish the right dose of DOCP, but when that is achieved Yanka should be able to live a normal, happy life.  I have known dogs to live until they are 16 years of age with well controlled Addison's disease.

I hope this is useful.

Best wishes
Jo
#2
Hi Alistair

Your poor girl has been through a lot.  The good news is the SRMA seems to be in remission, and in herself she is very well and happy. 

Years ago it was usual to prescribe Omeprazole or other gastroprotectants when on high doses of prednisolone because of the potential issues that you have described.  In recent years, giving a gastroprotectant when on high doses of preds, is no longer practiced and therefore gastric ulcers are not uncommon.  Omeprazole is given to heal the ulcers.

I am sure you have tried everything, so please forgive me if you have considered the following.

Give smaller meals and more often.
Do you know if the gastric ulcers are healed and no longer present?   
Is the vomiting that she is producing digested or undigested food?  Is it bile?
Have you recently changed her food?
Is she fed raw, wet or dried food?
Is she drinking enough, or could she be dehydrated?
Does she still need Omeprazole, or another proton pump inhibitor, to allow the ulcer to heal fully?
Does the diarrhoea indicate that there may be a bacteria present that needs an antibiotic such a metronidazole?  Metronidazole also has the ability to slow down the gut and allow more time for the water to be removed, thereby producing firmer stools.

My feeling is that her stomach, and probably her whole digestive system, has to be given more time to return to normal. It has been through a rough time.
 
When she is off preds, then perhaps a probiotic can be given, but this is not advised while there is some level of immunosuppression, although 5mg a day is not a high dose. Acidophilus is a very good gut bacteria. 

Is the vet intending to reduce the preds further?  If so then perhaps you could give 2.5mg a day (see the Prof. MJ Day Protocol) and then reduce to 2.5mg every other day and then leave it off altogether.  This will have a good effect on her stomach, but only if your vet is happy that she is in remission. It is always a balance between resolution of the disease, and the side effects of the drugs. Sometimes a different immunosuppressive drug has to be given to lessen the side effects of the steroids, and your vet did this with Atopica.  It is not a very well tolerated drug, so I am not surprised, but there are many other immunosuppressive drugs that are available now, should the need arise, but she now seems in a good place, so fingers crossed! .

Relapses are not uncommon, but it is hoped with SRMA that long term remission can be achieved, and there is no longer the need for steroids.  Anecdotally, SRMA is something that often occurs in a young dog and although in the first year or so relapses can occur, long term remission is expected to follow. A good immunosuppressive drug protocol is essential. 

Trigger factors are key to maintaining remission, and although it is impossible to protect from all potential triggers such as hormones and stress,  any potential known triggers should be avoided, these include regular spot on treatments, worming and vaccinations etc.  If a dog has worms or fleas then treatment has to be given, but only if necessary. I asked the head of the RVC, if a dog has an AI disease should they be vaccinated again, and he said NO! He said that the benefits and risks have to be considered, and in a dog with a genetic predisposition to AI disease the risks are too high.   So be mindful of these potential triggers.

I hope you had a positive experience at the vets today.

Best wishes
Jo



#3
That information is appreciated Amy.

Thank you.

Jo
#4
Hi Amy, and thank you for taking the time to post an update on Skylar, and even though many years have passed, I know how difficult this must be to relive the sadness.  It never leaves us, we just have to learn how to manage it over time. They are our family for sure.  You have been through such a tough time with your family too. I do hope that that dark cloud has lifted for you, and for so many others who seem to have gone through unprecedented hard times. 

I appreciate the information you have given about Skylar's condition because even if it helps just one person who has a dog with similar symptoms, your posting has done a good job.  Anyone who has experienced looking after a dog with seizures knows how traumatic and unpredictable it is, let alone the other problems that you and Skylar had to manage.  She was a lucky girl to have had you for her family.

Wishing you and your family all the best for 2024 and beyond.

Take care

Jo




#5
Hi Erica

I am so sorry about your dad's passing, and your mum's struggle.  Life can be so tough at times.  I understand why you have put your life on hold but it can take its toll, both emotionally and physically. 

You are doing all that you can to avoid 'triggers' but sometimes the trigger just can't be identified, and so many dogs have an AI disease when they are young and do achieve long term remission.  I hope this is true for Elsie.

Fingers crossed Erica.

All the best

Jo


#6
Hi Erica

It is such good news that Elsie has reached remission and has been well for 8 months.  What you have to limit now are the 'triggers' as she will remain in 'normal mode' unless she encounters something that will trigger the immune system into targeting its own body.  The triggers that you need to avoid are unnecessary drugs, regular flea treatment, wormers etc, vaccinations, stress, hormones (which is not easy when a dog is entire) etc.,etc.......

I asked the top Vet at the RVC if a dog that has had an AI disease should ever be vaccinated again, and his reply was No. He continued to say that the risk/benefits have to be considered, and the risks to a genetically predisposed dog is too great.  Do your own homework on the and a good website is WSAVA  vaccination guidelines.

Great news though.

Jo

#7
Fingers crossed for Oliver.  Great news.  Should he start to show signs again then please consider SRMA.  Thank you for the update.

Jo
#8
I hope you can find the right way forward for Oliver very soon.   

If Oliver has to have a sedation for his neck x-ray, and this doesn't prove to be diagnostic, perhaps a spinal tap should follow immediately after. 

Wishing him much better. Fingers crossed.

Jo
#9
Hi

I am so sorry that you have then need to contact us again but, hopefully now, you will have enough information to have a productive chat with your vet and get Oliver treated and on the road to recovery.

From the information that you have given, and also having been in contact with many Whippet owners over the years,   on top of the list of differentials I would, as you suspected, put SRMA.  I have known many Whippets to have SRMA, and so they can have a genetic predisposition, and for Oliver at his age to be displaying extreme pain, especially when his neck is moved, I would suggest that this is the most likely cause of his current problems.  SRMA is definitely diagnosed by examination of fluid via a spinal tap.  If you are not able to agree to this procedure, for whatever reasons, then if you have vet who will work with you then he or she may be willing to treat speculatively by giving an immunosuppressive shot of dexamethasone, and if there is remarkable improvement then a presumptive diagnosis can be made and a complete course of immunosuppressive treatment can be started within 2-3 days. 

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.  Neck is often held in a low, stiff position and the dog shows a reluctance to move head.
Depression.
Diagnosis:  Evidence of immune cells via spinal tap and clinical signs.
Treatment:  Immunosuppressive doses of Steroids/cytotoxic drugs

The good news is, SRMA is not life threatening and if treated correctly, long term remission can be reached.  A relapse may occur, but that is often because the dosage has been reduced too quickly and immunosuppressive therapy has to be started again.  I have known numerous dogs with SRMA and although it is extremely painful, it can be brought under control very soon after starting immunosuppressive treatment.  The inflammation in SRMA is reduced very quickly, and the dog starts to feel better within 48 hours, and some feel much better, and without pain, much sooner. 

The best reducing immunosuppressive protocol that I have come across is by Prof. Michael J Day.  See below:

Reducing the Tablets
When significant improvement in the dog's condition is seen, usually between 10-28 days, the initial steroid dose is usually reduced by 25%. The dose is generally given for another 10 - 28 days and depending on the dog's progress and clinical signs the dose is significantly reduced once more for a further 10-28 days; and again, in another 10-28 days. Anecdotal evidence has shown that if at this stage the dose is lowered more slowly, or reduced to an every other day dose over a period of months rather than weeks, relapse are less likely to occur.  It is always tempting to get your dog off steroids as soon as possible, but when treating autoimmune disease, as long as the dog is on a low, every other day dose then taking the last stage slowly seems to work best, depending, of course, on the severity of the disease and allowing for the difference in individual response - no two dogs reactions are exactly the same.  With some autoimmune diseases such as SLE, the dog is likely to be on steroids for the rest of his life. Usually, an every other day dose can be achieved, but you risk a relapse if you take the dose too low. Below is the best example of a reducing immunosuppressive protocol I have come across. It is an excellent guide and can be tailored to the individual.


Example: Reduction Protocol for prednisolone:


Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael Day BSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.


This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.
Prednisolone:  "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.


Merlin had IMTP which is a life threatening AI disease.  The treatment protocol is the same, although SRMA should be easier to treat, and you will hopefully see a much happier Oliver soon after starting treatment.

If you have any queries, please get back to us.

All the best

Jo




#10
Hi Helen

If the scabs are back on Psalm's lips and nose, then is is most likely that the disease is not in remission and treatment may have to be resumed.  There are other immunosuppressive drugs that can be used, or even try something like Doxycycline and niacinamide, which is not a quick fix but it is successful in treating some AI skin diseases.

Personally, I would be reluctant to feed raw if she was on immunosuppressive therapy, because her resistance to bacteria would be almost non-existent.   

Jo   
#11
Hi

I am pleased that you found the info' useful.  Prof Brian Catchpole is at the top of the tree and he has done lots of work research etc., with autoimmune disease.  He is a really good guy and can be trusted.

Personally, I would avoid any invasive investigations unless absolutely necessary, especially while Millie is on immunosuppressive doses of steroids.   High doses of steroids can inhibit wound healing and therefore surgery would not be recommended until the dosage had been significantly reduced.

I hope you have a good meeting with your vet.

Jo
#12
Hi

Poor Mabel, and you too.  It is so stressful looking after a dog with an inflammatory AI disease, and dealing with relapses.  Clearly, the spaying and vaccination have triggered these relapses.  At least she will not have anymore seasons, which can also be a trigger for AI disease.  Also, anything like vaccinations, and any spot on, worming, or other treatments etc., that are just preventative and unnecessary should not be given.  Limit any potential triggers as best you can - I know that isn't always easy but it is necessary.


1. She is awful on the high doses. Like a totally different dog who is largely absent and miserable. Therefore I'd like to reduce to 1mg/kg after 2 weeks. Then 3/4 weekly tapers. Any suggestions?

My personal opinion, reducing the pred dose by half after 2 weeks is risking another relapse, unless of course a second immunosuppressive drug is given alongside the preds.  Using two immunosuppressive drugs is common, especially if the dog has relapsed and the steroids treatment has to be started over again.  Something like, Mycophenolate Mofetil, or leflunomide is really worth consideration. Also, these drugs have a short lead-in time of about 4 days, which is good. If you reduce the preds too soon, then it is likely that the immune system wouldn't have returned to normal function in that time, so as you release the immune system, by reducing the preds, any aberrant immune cells that are programmed, resulting in SRMA, will become active and another relapse will occur.

The best immunosuppressive drug protocol that I have come across is by Prof. M J Day.

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.

Prednisolone:  "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.


2. We don't bother with bloods (vet and I). We see the vet when we need (each time she is poorly) but are now maxed out on insurance so keen to manage without diagnostics. Plus the signs are really clear. Is this ok?

The symptoms of a relapse will be the same as before and usually the vet can treat speculatively.  If the response to the steroids is as you would expect, then the presumptive diagnosis can assumed correct.  The least invasive tests that you do for Mabel the better.

3. Both times on steroids she has been really sick on omeprazole (and when not on steroids after a small incident with ibuprofen - it is a known side effect but therefore I cannot give her gastric protection. Any suggestions? (I always give the steroids straight After or with food)

Ibuprofen is very toxic to dogs and should not be given.
https://www.petpoisonhelpline.com/poison/ibuprofen/

If Omeprazole doesn't agree with Mabel then there are other gastro' drugs that can be given eg., Sucralfate  or Cimetidine, famotidine (Pepcid) etc.  Your vet may also prescribe others if necessary.  Gastroprotectants are not used as much these days when a dog is on high doses of steroids.  Personally, I still think they are worth giving, especially is the dog is struggling with reflux. Avoid giving any gastroprotectant within a couple of hours of giving other drugs as they can inhibit absorption. Certainly, Omeprazole should not be given within one hour of other drugs, or it should be given at least two hours 'before' any other drugs. Yes, always give preds with food.

4. She has had giardia twice while on steroids and required admission. Any gut protecting recommendations? I worm with panacur regularly.

When the immune system is significantly suppressed, infections and parasites etc., can occur. If a dog has worms then you must treat, but I would avoid any preventative treatments in a dog that is genetically predisposed to AI disease because these are potential triggers. I would test first and if there is a particular bacteria or parasite, treat appropriately then, but not on a regular basis, if it is not necessary. 

5. During her vet exam this time she was noted to have a hard lump inside her rectum. NOT related to her anal glands. Vet flummoxed. Anyone here ever had anything similar?

I can't help here, but it is something that the vet can check on every time you visit.  Hopefully it was something, maybe like a benign polyps that may never be a problem. 

6. At what point do you consider low dose steroids for life to protect against relapse? It's the horror of the high dose and her total personality change and misery that I hate.

No low dose of preds will prevent a relapse.  If necessary, it might control a systemic AI disease, but relapses can still occur if a trigger is met and the dose would be raised and then tapered again. A daily dose high enough to prevent an AI disease, would not be tolerated by the dog as the side effects would be too extreme.

The dogs that I have known to have SRMA are very often young, and one or two relapses are not uncommon. The aim of successful treatment is to achieve long term remission.  Just because Mabel has relapsed twice doesn't mean that she can't achieve long term remission.  I have known many young dogs to have relapses, but then, after a while, go on to be stable and never get it again. 

A dog cannot develop an AI disease without a genetic predisposition, which you can do nothing about, and then it is triggered by something which can be identified, as in Mabel's case, or in many cases the trigger is not known.  So  when Mabel's dose is weaned down, and eventually withdrawn, all potential triggers have to be avoided, and this includes vaccination.  I attended a seminar at the RVC about vaccination, and I asked Prof Catchpole: If a dog has had an AI disease, should it be vaccinated again?  His reply was "NO".  He went on to say that always, the benefits and risks have to be weighed up and in this case the risks are too high.

 If you want to know if a dog has immunity to the core diseases then you can have an antibody titre blood test done.  This proves immunity - just vaccinating a dog, assumes immunity.  I am certainly not against vaccination, far from it,  but annual vaccination is not necessary because the core diseases are  live virus vaccines that give many years of immunity, and sometimes for the life of the dog.  Please read the vaccination guidelines:

https://wsava.org/Global-Guidelines/Vaccination-Guidelines/

Mabel is only 20 months, and I honestly feel that there is no reason why she can't achieve long term remission, without maintenance drugs.  See this current therapy to the end, but take the last stages of treatment slower, and gradually wean her off the steroids.  I am very hopeful that this will happen for Mabel.

Best wishes
Jo


#13
Hi Jen

Ally has done so well, especially as her bone marrow took a long while to kick back in and also with all the drugs that she had in trying to being the disease into remission.  Great news!

Unfortunately, the very high doses of prednisolone, and over a prolonged period of time will produce some very harsh symptoms of drug induced Cushing's syndrome, and calcinosis cutis is most definitely as a result of the immunosuppressive steroid treatment and is a result of excess calcium.  I do hope the lesions are not too bad.  I have seen some very extreme cases of CC and sometimes the vet will want to remove the crusting lesions by surgery.  Personally, I would avoid this at all costs.    You need to keep Ally as natural as possible and avoid any potential triggers for sparking off another AI disease. It will take some time, maybe months before her skin looks healthy again. The sooner you can reduce the steroids and wean her off the better.  She is still on Mycophenolate, so this will support the reducing protocol that she is on now.

 I do think there are some supplements that you can give that would most certainly help the skin to return to normal function and assist removal of the crustiness.

Essential fatty acids are known, and have proved, to be invaluable to repairing skin because they are anti-inflammatory, and as the name suggests they are essential to healthy skin. EFA's should be given in relatively high doses to achieve the required results. I would start at 500mg of Omega 3 and 500mg of Omega 6 and then increase over a couple of weeks.  Too much oil, too quickly, can cause a loose tummy but gradually introducing it will be OK.   Also, I would add Natural Vitamin E as this encourages new cell growth and it prescribed in so many skin conditions.  It has to be the natural one though, because the synthetic form of vitamin is much less potent and the benefits are very low. 

Extract from my seminar notes below. 

EFA Ratio/Supplements
The 'therapeutic' dose of recommended supplements, in the treatment of autoimmune skin disease, often varies from one clinician to another.  Below are some examples with their references.
Quote: "Research is being performed to determine the optimal ratio of omega-6 to omega-3 fatty acids that should be consumed. Previously, it was thought that the ratio should be approximately 15:1. Current recommendations are for ratios of 10:1 to 5:1." (Omega fatty Acids: sources, Effects, and Therapeutic uses in Dogs, Veterinary Services Department, Drs Foster & Smith, Inc.  Holly Nash, DVM, MS)
Example Therapeutic Dose: Essential Fatty Acids
Quote: "Effect appears to be dose related and optimum doses and the most effective combinations of these oils have not yet been determined. Daily doses of Evening Primrose oil 172mg/kg/day, and Fish oil @ 44mg/kg/day, have been used in dogs over a one year period without ill effects". (Ref: The Veterinary Formulary by Yolande M Bishop)
•   EFA dose should start at a high level until a response is seen.  This can take up to 12 weeks. EFA's can cause loose stools. If this occurs, start on a lower dose and build up to the highest dose over a couple of weeks. Avoid using Evening Primrose Oil in dogs with epilepsy.  Always follow manufacturer's dosing recommendations.
Manual of Skin Diseases of the Dog and Cat by Sue Paterson – Drug therapies for onychodystrophy
Essential Fatty Acid    Dosage differs with individuals   
EPA 400mg/10kg    (Omega 3 -  e.g., fish oil etc.)
GLA 100mg/10kg    (Omega 6 – e.g., evening primrose oil etc.)
Biotin         2.5mg/dog once a day
•   Natural Vitamin E (400-800iu/12hrs) encourages new cell growth.  (Ref: Clinical Immunology of the Dog and Cat by Michael J Day). 



https://www.petmd.com/dog/care/fatty-acids-pet-skin-and-haircoat-health


I have no personal experience using something called DMSO, but it might be worthy of consideration or at least a discussion with your vet. See these links:

Veterinary Record Case Reports
Companion or Pet Animal
Resolution of iatrogenic calcinosis cutis in a dog through topical application of DMSO


https://bvajournals.onlinelibrary.wiley.com/doi/abs/10.1136/vetreccr-2018-000619


Salt water is a good cleanser, but I have recent experience of looking after someone with inflammation around a port inserted in their chest.  I was using salt water to bathe it, but when I asked the nurse she advised making a paste of bicarbonate of soda and leaving it on the sore area for about 5 minutes and rinsing off.  It really worked wonders, so it might be worth trying a solution of bicarbonate of soda instead of salt to see if that has any added benefits. Just a thought!

The good news is that Alley is in remission from non-regenerative AIHA.  It has been a tough journey, but she is on the mend, which proves that if you can take away the aggressor (the aberrant immune system) her body will fight to get back to normal function and repair.  The eventual withdrawal of immunosuppressive medication will complete the process.  Her body needs time now, to fully recover from the drug induced Cushing's, and that is not only her skin, but muscle weakness etc......

I really do think that supplements will assist, and very likely accelerate the healing of her skin.

Fingers crossed

Jo
 







#14
Hello everyone

As we enter the year 2023, you and your dogs are wished the very best that life can bring including; lots of walks, lots of treats and most of all lots of love and good health.

Best wishes and Happy New Year to you all.

Jo and Sheila
xx
#15
That is great news Erica

Many thanks for the update.  It is lovely to have good news.

Personally, I wouldn't change anything.  If the diet suits her, then don't change it.

Best wishes
Jo