CIMDA

Other drug options, if your initial choice doesn't work, can include:
(Chlorambocyl, Gold salts, Pentoxifylline, Retinoids, Azathioprine, Atopica)
•   Pain Relief especially in the early stages or after surgery may be necessary, eg. Tramadol.
•   Essential Fatty Acids (EFA's) are given in therapeutic doses, regardless of which primary treatment regime is used.  High doses of EFA's play an `active' role in the treatment of skin diseases and should be included in the treatment regimen and in low maintenance doses after remission.  EFA's are known to be `steroid sparing' in high doses. This means that they have anti-inflammatory properties which may ultimately, lead to a lower dose of steroids being used and this is especially useful in dogs that remain dependant on steroids. However it is not easy to find a specified dose that is consistently used.  Examples 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). 
•   Chinese herbs are also noted as being effective but the owner should consult a vet who practices in natural treatments.
Biotin (5mg/kg/day: Ref: Muller, Kirks Small Animal Dermatology)
•   Improves the quality of the nails but it can be difficult to obtain. Some dogs with SLO have shown to be deficient in biotin. This may be due to their diet.  Foods with a relatively high biotin content include cooked eggs, liver, chicken livers, kidneys, some vegetables eg., boiled broad beans, raw or canned tomatoes, raw cauliflower, dried skimmed or whole milk, fresh milk, bran, yeast and raw egg yolk.

Note: Do not give raw egg white as it contains a substance called avidin which binds to biotin and prevents its absorption. This does not apply to cooked egg whites as the cooking process deactivates avidin.
•   Gelatine – 10 grains (one capsule) every 12 hours. Ref: Muller, Kirks Small Animal Dermatology.  Some owners give 1-2 cubes of jelly every day.
•   Good quality high protein diet in case of nutritional deficiencies.
•   Antibiotics if secondary infection is present
•   Topical acrylic nail cement applied externally to permanent nail deformities, which suffer from re infection.  Nails could be strengthened and protected by this application.
I have not known a dog to have external acrylic nail cement treatment but reference to this can be found in Muller, Kirks Small Animal Dermatology.

•   Removal of loose nails Loose nails may have to be removed, usually under anaesthesia. As you can imagine, recovery from this procedure is likely to be very painful and prolonged, especially if nails on several different feet are affected.  Clipping, cleansing, removal of the fractured portion of claws may be necessary even after treatment is well under way.  Understandably, most dogs with SLO become very sensitive to their feet being touched.

Topical shampoos, Antiseptic soaks (Salt or Epsom Salt foot baths, Hibiscrub etc.) Initially it may be necessary to bathe your dog's feet to keep them clean and to wash off the blood etc., but once they are dry and healing it seems better practice to try to keep their feet dry.  Antiseptic soaks or salt soaks will help to soothe and clean.  Epsom salt soaks are reported to be very soothing when the dog has pain. When the feet are sore and weeping, you can use socks and boots (or strong plastic bags tied with string) to offer protection when out

Symmetrical Lupoid Onychodystrophy (SLO)    by Jo Tucker

Definition:
Symmetrical:  Affecting corresponding parts simultaneously and similarly.
Lupoid:   Comes from the word lupus meaning any of a group of skin diseases in which the lesions are characteristically eroded by the immune system.
Onychodystrophy:  Abnormal claw formation.
SLO comes under the heading of an autoimmune skin disease.

Disease process:
SLO is an autoimmune disease whereby the immune system becomes confused and spontaneously produces an aggressive antibody response, which infiltrate and kill the good cells of the nailbed and surrounding area, causing the nails to fall off or grow deformed.
The term `autoimmune' is used when the immune system destroys good cells for no apparent reason i.e. there are no underlying causes such as infectious or chronic disease.
There are many different autoimmune diseases.

About the Immune System

The immune system is a very powerful and complex tool.  It is designed to protect the body, keep it healthy and free of disease. The immune system consists of an army of immune cells that lie in wait for foreign invaders such as, bacteria or a virus, known as antigens.  When an antigen is identified, the immune cells multiply and are despatched to destroy the antigen without mercy.  When their job is done the immune system returns to normal balance. 

To ensure the immune system identifies and kills only the foreign cells, it develops a memory to distinguish between what is:

'Self' – the good cells - its own body 
 and

'Non-self' -- the bad cells – foreign to its body.

Autoimmune Disease
Autoimmune disease can occur when the immune system of a genetically predisposed dog malfunctions and is no longer able to distinguish between what is 'self' and what is 'non-self'. 

These dogs will develop an autoimmune disease if their immune cells mistake a part (or parts) of their own body as a foreign invader. The immune system will aggressively respond and produce antibodies that are programmed to destroy the bad `foreign' cells, and in doing so unintentionally destroys the good `self' cells, resulting in a primary autoimmune disease. It is clearly a case of mistaken identity.
For this breakdown in the system to occur the dog has to have a genetic predisposition.  This concealed predisposition is undetectable until an autoimmune disease occurs.

Genetics
A dog that develops an autoimmune disease has inherited these damaging genes from both parents. The mode of inheritance is known to be complicated, with several genes involved. This is often referred to as a polygenic inheritance.  Although both parents carry the genes responsible, and it is known to run in families, this does not necessarily mean that if one dog in a litter gets an autoimmune disease the others will follow.  Also, it is not known why dogs develop a specific autoimmune disease, or in some cases develop more than one.  It may be due to the combination of inherited genes (or lack of them), different environmental influences, or a particular set of untimely circumstances that triggers specific diseases in a predisposed dog.
It is unfortunate that currently, there are no DNA tests available to identify the dogs who are genetically predisposed to autoimmunity, or `carriers' or genetically `clear' dogs.  This means that dogs with a genetic predisposition can only be retrospectively identified after a diagnosis of an autoimmune disease, because prior to this they will appear relatively normal. A confirmed diagnosis identifies both parents to be at least `carriers' of autoimmune disease, but they may go on to develop an autoimmune disease if they carry a full quota of deleterious genes.   
 
Age
Autoimmune disease is more likely to occur in young to middle aged dogs, but occasionally dogs as old as 16, have been known to develop an autoimmune disease.
Gender
Both male and females are affected however, it is thought that young females seem to be more prone - and this probably due to hormonal influences.  Hormones can be a major trigger factor for autoimmune disease in the dog.

Triggers 
It has already been stated that a genetic predisposition is required for a dog to develop an autoimmune disease, but that's not all as it has to encounter a `trigger' to generate an immune response and, in so doing, the malfunctioning immune system produces auto-antibodies that are programmed to destroy its own cells.
So, what are trigger factors?
Anything within a dog's environment that may challenge their immune system can be a potential trigger.  A dog that develops an autoimmune disease may have encountered the same trigger factor before with no detrimental effect, but for some unknown reason, on this occasion it has caused the immune system to malfunction resulting in the dog developing an autoimmune disease.
Possible trigger factors are:
1.   Stress eg., fireworks, thunderstorms, separation anxiety, whelping, hormones etc.
2.   Viral or bacterial infection.
3.   Adverse reaction to chemicals, drugs or vaccines.

SLO
SLO can be `primary', meaning it can occur in isolation, or it can be `secondary' to another autoimmune disease such as, pemphigus skin disease; or SLE, a multi-systemic autoimmune disease which is far more serious, but thankfully, uncommon.
Unlike some other autoimmune diseases, primary SLO is not life threatening but it is a very painful and miserable condition until the correct treatment is well under way.  Primary SLO involves the nails and surrounding area of the feet only. Multiple nails on different feet are always affected, but this can take several weeks or even months to fully develop.
A dog with secondary SLO will show other signs of being unwell eg., footpads and other areas of skin affected, very high temperature, lameness, anaemia etc......
Nail problems have been a concern to dog owners and breeders for decades. This condition was always referred to as a `nail bed infection'.  However, it was not until 1997, following an article written by a veterinary dermatologist and published in the Southern Counties Bearded Collie Club's magazine `Beardie Times', that owners started to worry that this might have a genetic link. The article suggested SLO was not an infection but an autoimmune disease, and this has subsequently been confirmed by various studies. 

Alternative Diagnoses
In addition to SLO being linked to other autoimmune diseases, various nail disorders can also be caused by:
•   Trauma (very unlikely to involve nails on different feet)
•   Infection – bacterial, fungal (again, very unlikely that all nails are involved)
•   Endocrine problems: (eg., resulting from an underactive thyroid or Cushing's syndrome)
•   Nutritional causes

Clinical signs of SLO can include:
•   Lameness, swollen toes.
•   Loss or partial loss of nails, licking of feet.
•   Bleeding and/or discharge from the nail or surrounding skin.
•   Deformity caused by abnormal growth.
•   Secondary infection.
•   The dog is generally well, but might be miserable and depressed due to the pain.
The disease is progressive and it can take months before all nails are affected. Blood tests will be unremarkable, but a full blood test is advisable to first rule out the possibility of an underlying disease.

Wrong Diagnosis
Initially, only one or two nails might be affected.  It is therefore common, and not unreasonable, for a vet to assume a diagnosis of bacterial or fungal infection and treat accordingly. Treatment can go on for several months before both the vet and owner realise that it is not working.
The longer SLO is left without appropriate treatment, the more nails become affected. Secondary infection is very likely because the feet are in contact with the ground and the dog will naturally lick his sore feet which may also cause infection.

Clinical Signs
If your dog has a nail problem, the first thing you may notice is when he cries out in pain and limps, or licks his foot. Also, nails can bleed profusely and this can be quite alarming to start with.  It would be natural to think that he has caught his nail on something that has caused it to bleed.  It is probably not until a second or third nail breaks that you might start to wonder if this is more than just accidental damage to a couple of broken nails. Of course, one lost nail may be due to trauma or even an infection, but if the problem extends to other nails on different feet - then it is likely to be SLO.   

Diagnosis
A diagnosis of SLO can only be confirmed by the amputation of the first digit of a preferably, non-weight bearing toe (the third phalanx) or the complete removal of an affected dew claw. This enables the pathologist to identify infiltrating immune cells (principally from the coronary band at the base of the nail which is buried deep beneath the skin) and confirm the diagnosis.
The complete removal of an affected dew claw is preferable as it has much less impact on the dog and it minimises post-surgical pain, management and trauma.  A punch biopsy is not recommended as it is difficult to perform and rarely gives conclusive results.  Nails that have previously broken off are of no diagnostic value at all.

Presumptive Diagnosis
A confirmed diagnosis of SLO is valuable information for the vet, owner and the breed. However, if the amputation of the end of a toe, or total removal of a dew claw, is not something you want to put your dog through and you would rather consider and accept the overwhelming clinical signs and treat speculatively for SLO, then the following observations are important to recognise:
•   SLO is the most common cause of symmetrical nail disease in dogs.

•   Family history, age of dog and known breed predisposition.
•   Loss of nails on multiple digits, without evidence of systemic disease, is distinctively characteristic of SLO.
•   SLO is progressive. Initially, only one or two nails are affected. Consider SLO if further nails become damaged, despite the dog receiving prolonged antibiotic therapy and other supportive treatment?
•   Signs of improvement after correct treatment has started.

How do you control the immune system and get it to behave normally again?
Drugs are used to significantly suppress or regulate the immune system in order to stop the destruction and allow the body to heal and work normally again. When clinical improvement is seen, the drugs are reduced over a period of time, slowly releasing the immune system back to normal function and hopefully, achieving a state of remission. 
There is no cure for autoimmune disease but long term, remission can be achieved. Some dogs will stay in remission without drugs, but others need a low maintenance dose for life.     
Dogs may have an autoimmune disease only once and never get it again but there is always a possibility that a predisposed dog could relapse or get another autoimmune disease at a later date.

 Treatment Options for Autoimmune Skin Disease
Fortunately, there are different treatment options for autoimmune skin diseases and as primary SLO is not life threatening, the most popular treatment seems to be with either Doxycycline, Tetracycline or Minocycline, with Niacinamide (Vitamin B3).
Doxycycline, Tetracycline and minocycline are from a group of antimicrobial drugs that come under the heading of Tetracyclines.  There are over 6 different antimicrobials in this group but only tetracycline, doxycycline and minocycline are indicated in the treatment of SLO and other autoimmune skin disease. 
Doxycycline, Tetracycline and minocycline are antibiotics which also have anti-inflammatory properties and suppress antibody production. They are immunomodulating drugs, meaning that they have the ability to adjust the immune response to a desired level. They are known as 'steroid sparing' meaning that the molecular effect is similar to using steroids.
An antibiotic in this class of Tetracyclines, commonly used in veterinary medicine, is Oxytetracycline but it does not have the same properties as those listed above, and is not indicated for the treatment of autoimmune skin disease.
Niacinamide works with Doxycycline, Tetracycline or Minocycline to further suppress antibody production and provide additional anti-inflammatory and immunomodulatory effects.
Important Notes:
1.   Tetracycline should be used with caution in dogs with renal impairment as it is eliminated from the body via the glomerula filtration and a build-up of the drug can occur if used for prolonged periods. If it is necessary to give a dog with renal impairment Tetracycline the dose should be lower than recommended, but a lower dose may not address the problem of SLO, and also the treatment is likely to be for many months at least.  However, Doxycycline is excreted in the faeces and does not affect renal function and can be used for animals with renal insufficiency. (Plumb's Veterinary Drug Handbook)
2.   Niacinamide is also known as nicotinamide but it must not be confused with, Nicotinic Acid, (Niacin). Although Niacin acts identically as a vitamin, it increases the blood flow and blood pressure, and should not be used for the treatment of SLO. See this link:
    https://niacinreviews.com/difference-niacin-niacinamide-non-flushing-vs-flushing/
If you are in doubt as to which product to buy, look for niacinamide or nicotinamide 'Non-flush' label. 
Recovery:
Unfortunately, it will take 1-3 months before any positive results are seen (although duration of treatment is much longer, probably 6-12 months on a reducing dose regimen) but, in spite of this, it does seem to be the treatment of choice for SLO as it is effective and usually well tolerated - and it avoids the use of steroids and other stronger drugs.  Most dogs do very well on this treatment regimen. When good clinical improvement is seen the drugs can be gradually reduced and the dog weaned off medication over a period of many months, or remain on a low maintenance dose. 
Dose:  Tetracycline with Niacinamide
*Ref: Plumb's Veterinary Drug Handbook Eighth Edition.
*Dogs weighing less than 5kg : 100mg niacinamide, 3 times a day.
*Dogs less than 10kg : 250mg each Tetracycline and niacinamide three times a day.
*Dogs more than 10kg : 500mg each Tetracycline and niacinamide three times a day.
Give three times a day until improvement is seen, 3-6 months.  Then give twice a day for 2 months, then once a day for maintenance. (Manual of skin Diseases of the Cat and Dog 2nd Edition, By Sue Paterson).
Note:  Food or dairy products can significantly reduce (up to 50% or more) the amount of Tetracycline absorbed.   Avoid giving oral tetracycline within 1-2 hours of feeding or giving milk or dairy products.
Doxycycline with Niacinamide
Historically the use of doxycycline, instead of Tetracycline, for autoimmune skin disease was much more convenient because unlike tetracycline, dairy products do not affect its absorption and the recommended dose was 5mg/kg/once a day (Plumb's Veterinary Drug Handbook, Fifth Edition). 
The new *Plumb's Veterinary Drug Handbook, Eighth Edition, recommends the dosage as:
*Doxycycline: Consider 5-10mg/kg/twice daily
or
*Minocycline - Consider 7.5mg/kg twice daily
The dose of Niacinamide (see above) is the same regardless of which combination drug is used.

*Tetracycline – avoid giving drug orally within 1-2 hours of feeding, giving milk or other dairy products.
*Doxycycline and Minocycline – Oral doxycycline and minocycline can be given without regard to feeding. Milk or other dairy products do not significantly alter the amount of doxycycline or minocycline absorbed.  Do not give as a dry pill.  Give with a moist treat or small amount of liquid to be sure that it reaches the stomach.
*Do not give multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after giving doxycycline. These products can reduce the drug's effectiveness.
*Ref:  Plumb's Veterinary Drug Handbook Eighth Edition
Note:  I have known numerous SLO dogs to achieve remission on Doxycycline: 5mg/kg/once a day but referencing both of these recommendations gives the vet licence to adjust the dosage if necessary.
Tetracycline or Doxycycline is usually well tolerated however, some dogs exhibit signs of nausea, vomiting or diarrhoea at the start of treatment, if this happens reduce the dose for a week or so and gradually increase to full dose.

Hi and welcome

I am sorry your boy has SLO.  From what you report the Pentoxyfillin is causing gastric problems, and unfortunately this is one of the side effects. If you decide to keep him on this treatment, then you may have to include a gastroprotectant.

I used to have bearded collies and they can have a genetic predisposition to SLO, and much work has been done on this over the last 20+ years.   I will put some information her, but if you would like the full seminar notes please email me at cimda@aslog.co.uk and I will be very happy to send them to you.

I have known countless dogs to have SLO and although it is an autoimmune disease, the good news is it is not life threatening, so the use of high dose steroids are not necessary.  Although pentoxyfillin is listed in the treatment of SLO, the majority of dogs that I know have been treated with Doxycycline and niacinamide, and other supplements such as essential fatty acids etc.  Doxycycline is from a group of antibiotics called Tetracyclines, and from the group of about 6 antibiotics there are only three that provide anti-inflammatory and immunomodulatory properties, which is necessary to bring SLO under control and into remission.  The best, and most convenient of these is Doxycycline.

I will post some info, but feel free to email me if you wish. 

Jo
 

Hi Rebecca

I am sorry that your girl has a sore crusty nose.  Yes, it certainly could be DLE, but to get a confirmed diagnosis the vet will probably want to do a biopsy, and to be honest the results often don't come back as conclusive, so personally, I would want the vet to treat speculatively rather than use a general anaesthetic and do a biopsy that may not show a conclusive result.

Some AI skin diseases can be successfully brought into remission without using very high doses of steroids. Doxycycline and niacinamide, along with Natural Vitamin E, and Omega 3 & 6 supplements have been very successful with some AI diseases.  I have known many dogs to be successfully treated in this way.

See the information below and have a chat to your vet about starting your girl on this regimen.

I hope your vet will work with you.

Jo


Here is an example:

: Manual of skin diseases of the dog and cat by Sue Paterson Table 11.1 

Doxycycline/niacinamide

Doxycycline: 5-10mg/kg twice a day
Niacinamide: Dogs over 10kg 250mg 4 times a day

Natural Vitamin E 400iu twice a day (see ref. below)

I would also give fish oil (Omega 3) and evening primrose oil (Omega 6)

Manual of Skin Diseases of the Dog and Cat by Sue Paterson
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.)

•   Natural Vitamin E (400-800iu/12hrs) encourages new cell growth.  (Ref: Clinical Immunology of the Dog and Cat by Michael J Day). 

See this link:

https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4952581


Below is an extract from my seminar notes for AI skin disease.


Discoid Lupus Erythematosus – DLE  (Cutaneous Lupus)
Discoid lupus is an autoimmune skin disease that causes depigmentation, and ulceration and crusting of the lips, nose and nasal planum, with loss of the 'cobblestone' appearance. It also affects areas around the eyes and sometimes the ears, often causing hair loss in these areas. Although the dog is not systemically ill, this condition is very painful, especially if the dog 'knocks' its nose and, as always with severe pain, this can make the dog very depressed.


A combination of tetracycline or doxycycline and niacinamide (Vitamin B3), and 'steroid sparing' supplements such as essential fatty acids and natural Vitamin E in therapeutic doses.
   
There is a group of five antibiotics that go under the heading of 'Tetracyclines'.  From this group, there is a choice of using one of the following:  Doxycycline, Tetracycline or Minocycline.  These antibiotics are not used for their antimicrobial properties but for their anti-inflammatory and immunomodulating effects, and the ability to suppress antibody production.  Any one of these three drugs can be used in combination with niacinamide (vitamin B3) for the treatment of immune mediated skin diseases.  It should be noted that food or dairy products can reduce the amount of tetracycline absorbed by 50% or more.  To maximise bioavailability it is recommended to administer the drug two hours before or after food. Unlike tetracycline, doxycycline is not affected by food or dairy products to the same extent (no more than 20% reduction) and this is thought to be insignificant. Doxycycline is also more convenient to administer because it is given only once a day, therefore Doxycycline is  preferred.

It takes 1-3 months before positive results are seen and treatment is likely to be continued for 6 months or more. Doxycycline with niacinamide seems to be a good treatment choice as it avoids the use of steroids and other stronger drugs.

 

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

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

That information is appreciated Amy.

Thank you.

Jo

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

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

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

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

Jo

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

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

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   

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