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Messages - Jo CIMDA

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1
Hi

Yes, a dog that has had one AI disease, and is therefore genetically predisposed to autoimmunity, can develop other AI diseases if they have the genetic predisposition to that particular disease and an appropriate trigger is met.

The problem with autoimmune/immune mediated gastrointestinal diseases is they often present in a similar fashion to non-immune mediated gastrointestinal disease such as a nasty bacteria (that can be sorted with an appropriate antibiotic), a virus, or even an allergic gastrointestinal disease which is either dietary or environmentally triggered.   

 It is most likely to be a colitis event caused by a bacteria or parasite than an immune mediated disease. This is a common cause of bloody diarrhoea.   It is not always easy to definitively diagnose gastrointestinal problems and this is why the vet may put the dog on antibiotics (often metronidazole)  and/or some probiotic paste and a bland diet to see if the problem resolves. 

If you want to do some research, here are some IM gastrointestinal diseases:

 Inflammatory bowel disease is a heading for several IM gastric conditions eg.,  lymphocytic enteritis, Eosinophilic gastroenteritis, Granulomatous enteritis, Lymphoplasmatic colitis.  Dietary hypersensitivity is also another possibility and there are a few IM gastrointestinal diseases which are breed specific.

 FYI:  Immune mediated gastrointestinal disease such as inflammatory bowel disease usually start with chronic vomiting, diarrhoea, weight loss, anorexia.    Clinical history will be taken and tests such as blood biochemistry and haematology checking for Vit B 12 and folate, and a TLI test for exocrine pancreatic insufficiency, and urinalysis, also a faecal test for bacteria and parasites such as giardia, campylorbacter, salmonella etc. Depending on those results an intestinal biopsy might be next to see if there is any inflammation or bacterial overgrowth and hopefully this will determine the specific immune mediated gastrointestinal disease. 

Personally, I wouldn't be thinking of this being immune mediated until you have exhausted all the usual speculative treatments.  I hope it isn't IM and things resolve very soon.

Jo
 

2
Hi

I doubt that stopping such a low dose, given every third day, would cause sudden weakness but sometimes when a dog is weaning down from steroids, as the dose gets low and if true remission hasn't been achieved (there is no way of knowing this),  the inflammation can start up again and so, if this is a relapse of his AI disease,  this might have been coming on slowly for a while without obvious symptoms. 

If true remission has been reached, and then a relapse occurs,  the dog has met a 'trigger' to have started the disease process off again.

Having said that, it may not be a relapse and it might be that he has just over done it with the other dog and has stretched his muscles and ligaments etc., (as if he has been in a gym) and they are aching.

Fingers crossed!

Jo

3
Extract from my seminar notes:

WHAT TO EXPECT ONCE IMMUNOSUPPRESSIVE TREATMENT HAS STARTED
If a dog has a serious autoimmune disease, then the sooner treatment commences the better chance the dog has of survival.  The main delay to starting treatment is obtaining a diagnosis or at least your vet being sure that he hasn’t missed anything that could be made worse by giving high doses of steroids.  Achieving a diagnosis can be a fight against time. 
If your vet has decided that in all probabilities your dog has an autoimmune disease, then to a certain extent, which autoimmune disease your dog has, as far as treatment is concerned, is irrelevant because with the exception of a few diseases, they are all treated the same, that is, with immunosuppressive drugs.  The main objective is to ‘knock out’ the immune system and virtually stop it from working (or near enough) so the destruction will cease and give the body a chance to recover.  As previously stated, this treatment regime works in most cases, that is, if it has been given early enough and the dosage is correct.  All dogs are different and some can tolerate the drugs better than others. In proportion to their size, small dogs seem more able to tolerate higher doses of steroids than large ones. Some diseases are more serious than others and carry a poorer prognosis. So the initial crisis is a crucial time, however anecdotal evidence shows that many more dogs survive than die if correct treatment is administered in good time.
It is hoped that a positive response can be seen within 4-6 hours of starting treatment (depending on the disease), but in a serious, life threatening situation, the first 2-7-14 days can be a very worrying time.  Assuming the dog has stabilised he will quickly feel much better, and if he is in hospital may be allowed home within a week.
When he comes home he will probably have a ‘goody bag’ full of drugs.  He will be on a high dose of steroid, usually prednisolone, and he may also be on another immunosuppressive drug, such as Azathioprine.  Your dog will be weaned off in a controlled manner according to his wellness and clinical observations. 
Note: High doses of steroids must not be stopped abruptly.  Your dog could go into an adrenal crisis if the medication is withdrawn too quickly. 
In addition to immunosuppressive drugs he should have something to protect his stomach from excess acid.  The last thing your dog needs when he is feeling poorly is a bleeding stomach ulcer caused by the drugs.  Sometimes, Antepsin is given to coat and protect the stomach (but this must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed. Another gastroprotectant used is Omeprazole. To minimise irritation to the stomach it is usual for the daily dose of steroid to be split into two doses and given with food, one dose in the morning with breakfast and the other dose with his evening meal. I have known several dogs, who did not receive a gastroprotectant as a part of their treatment regime, and went on to develop anaemia. This is not autoimmune haemolytic anaemia but iron deficiency anaemia caused by bleeding stomach ulcers. Using a gastroprotectant is a good preventative measure. When the steroids have been significantly reduced to a low dose, a gastroprotectant may not be necessary.
Excess acid, produced because of the drugs, may make a dog prone to developing pancreatitis. A dog with pancreatitis will appear in pain and his back may be arched as if he can’t straighten up.  He may be lethargic, seem bloated and have a tender abdomen. Dogs usually go off food and water, may vomit and look depressed.  If you suspect that your dog has pancreatitis, don’t try to feed him because it will make the condition worse. Take him to the vet as soon as possible as he may require treatment or need to go on an intravenous drip to stop him dehydrating.  Again, the risk of pancreatitis should be minimal once the dog is on a lower dose of steroids.   A low fat diet is best when your dog is on high dose steroids or prone to pancreatitis. 
As your dog‘s immune system is being significantly suppressed, he will be more likely to pick up infections, and will not have the ability to fight against them.  As a precaution a broad spectrum antibiotic is often prescribed. Also it is sensible not to exercise him in areas where he is more likely to encounter infections, for example, a park or a popular dog walking area. 
Whilst your dog is on high dose steroids he will want to eat and drink excessively. However, this also means that he will want to urinate more and this can sometimes cause temporary incontinence.  You may have to get up to let him out during the night and if you leave the garden door open during the day, it may save some mopping up!  He cannot help it and won’t like it either, so don’t be too hard on him, it’s only temporary. You will notice as he is weaned off the drugs the unwanted side effects will subside and he should return to normal habits and behaviour.  Urinary tract infections and/or bacterial skin pustules are not uncommon when a dog’s immune system is suppressed, and this is often the reason for a dog to be off colour during this time.  Note: Always consider a urine infection if your dog seems under par.  A course of antibiotics will usually sort this out quickly.
Depending on what autoimmune disease your dog has, he will probably need to have regular blood tests.  Biochemical blood tests will also keep an eye on other body functions, such as those of the liver and kidneys, which is important at this stage.
Assuming good progress is being made, the clinical signs of his illness are diminishing and positive signs of improvement are apparent, your vet will want to start weaning him down from the high doses of steroid.  This process can take 3-6 months or more, and usually begins any time after 10 - 28 days from the start of treatment, depending on the results of his blood tests and his clinical signs.
Relapses are not uncommon, especially in diseases that are difficult to control, for example SLE.  A relapse may mean that initially, your dog needed to be on a higher dose of immunosuppressive drugs for a longer period of time, or your dog may have been weaned off a little too quickly and then the dose withdrawn too soon.
If a relapse occurs he will probably show similar clinical signs to his initial crisis.  He will have to go back on an immunosuppressive dose of prednisolone, but it may not have to be quite as high as before. A combination drug may need to be added at this stage. The weaning process will then have to start all over again. Returning to an immunosuppressive dose will mean that he has to go back on a gastroprotectant.
 

Side Effects of the Drugs – Iatrogenic Cushing’s Syndrome

Iatrogenic Cushing’s syndrome is a side effect of high dose steroids and is caused by too much corticosteroid in the body. To a lesser extent, the immediate side effects observed when the dog initially goes on steroids eg., drinking, eating and urinating excessively is a mild example of Cushing’s syndrome.  Personally I like to see dogs responding to high doses of prednisolone in this way, as it means that they are responding to the drugs as they should.
Usually, Cushing’s syndrome only becomes a real problem when exceptionally high doses, or prolonged high doses of steroids are administered, maybe due to a relapse, or in some cases where the vet is inexperienced in reducing steroid doses and keeps the dog on a high dose for longer than necessary; or when the dog is not responding to treatment and higher doses are necessary to control the disease.  This is where the cytotoxic drug Azathioprine, and other more recently used, immunosuppressive drugs are very useful. 
All drugs carry side effects and Azathioprine is no exception, but it does not carry the same side effects as prednisolone, therefore by using this drug in combination with prednisolone it reduces the risk of iatrogenic Cushing’s syndrome.  As Azathioprine takes at least 10 days to take effect, starting the ‘combination’ therapy at the beginning of treatment may enable the prednisolone to be lowered within the 10-28 day band and still maintain a good level of immunosuppression. If your dog is not responding to treatment then your vet may consider changing his treatment to other immunosuppressive drugs.

How Can I Tell if My Dog Develops Iatrogenic Cushing’s Syndrome?
Iatrogenic means ‘drug induced’.  Clinical signs of Iatrogenic Cushing’s syndrome are the same as primary Cushing’s syndrome but can present with acute clinical signs. It reflects the level of corticosteroid in the body.
The most notable side effects are, heavy panting, some hair loss, and an increase in drinking and urinating, excessive pigmentation.  This is something everyone seems to be aware of and accepts as normal when a dog is on high dose steroids. Very often the dog will be weaned down to a low dose before any major problems arise. 
Acute Cushing’s syndrome due to overdosing of corticoid steroids can be very serious.  Blood results will reflect this, especially the liver enzymes which may be extremely high. Red blood cells and blood platelets may also be high and blood clotting may be a risk.
So when should you alert your vet to suspected, unacceptable level of corticosteroid?  The owner should take note when other clinical signs occur, such as: Depression, anorexia, muscle wasting and extreme weakness, continuous panting, lethargy - unwillingness to exercise, skin lesions and thinning of the skin, excessive hair loss, pot-bellied appearance and sagging back, behavioural changes (aggression).
If your dog is showing these signs it will probably mean that the dose of steroids needs to be lowered. It is important that it is not confused with a relapse of the dog’s condition or an infection. The dilemma is that steroids must not be withdrawn too quickly otherwise the dog may go into an adrenal insufficiency crisis.  If the clinical signs of iatrogenic Cushing’s syndrome is intolerable, it is hoped that the high dose of steroids that he has been on will have already done their job and that his autoimmune disease will be stable. As long as the steroids are lowered in a controlled manner and in time, all the symptoms of Cushing’s will subside and your dog will return to normal, but extreme signs must not be ignored.

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

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.


How Do I Know if My Dog Will Relapse?
Until you have attempted to wean your dog off of the tablets for the first time you will not know if he is likely to relapse or not.  Sometimes during the weaning off process, before you even get down to an every other day dose, he may relapse.  If this happens then the drug dosage has to be raised, probably up to the last dose before the relapse (maybe a little higher, depending on the severity of the relapse) and then start the weaning process again.  If this happens again, then you and your vet may have to settle for keeping him on a low maintenance dose to achieve a good quality of life. A low, every other day maintenance dose of prednisolone is preferred to enable the dog’s liver to rest in between doses. There are many autoimmune diseases that carry a good, drug free prognosis.  The more common, serious autoimmune diseases that may not need long term steroid therapy are: primary immune-mediated polyarthritis, autoimmune haemolytic anaemia and thrombocytopenia. However, as previously stated, all dogs are different and it very much depends on the individual dog, the severity of the disease, the experience of the vet and the vigilance and compliance of its owner.
If a relapse occurs whilst the dog is still being treated then true remission has not been achieved.  If the dog has achieved remission and has enjoyed a period without drugs or is on EOD maintenance drugs, when a relapse occurs or he develops another autoimmune disease, he has encountered a ‘trigger factor’ which has induced this change.

4
Hi and welcome

I am sorry that your Goldie had IMPA.  I presume that the IMPA had a good response to immunosuppressive doses of prednisolone?

Long term, high dose, pred use will cause drug induced Cushing's syndrome and it is clear, by his symptoms and the condition of his liver, that this is what your boy has, although 5mg a day pred isn't much of a dose for a Golden Retriever it is the build-up of excess steroid in his body that is the problem.

If he were mine I would go to every other day dosing of preds and gradually wean off, perhaps going from 5mg every other day for a few days to 2.5mg every other day and then leave it off altogether.

If his joints start to swell up and become painful then he should be put on a different immunosuppressive drug such as mycophenolate mofetil, leflunomide, cyclosporine etc.  See this article: https://www.dvm360.com/view/immunosuppressive-drugs-beyond-glucocorticoids

Sometimes it is more important to correct the side effects of the preds than to control the AI disease, and as there are alternative immunosuppressive drugs, until the Cushing's is at a level that he can tolerate, it is best to switch to a different drug.

Something like Denamarin or Denamarin Advanced  https://www.denamarin.com/#about-denamarin is an excellent liver support and should be given.

When your boy is off preds you should see a marked difference in him.  His belly should reduce, and over time his muscles will get stronger.  If you act now there should be no reason to put him to sleep because the liver is an incredible organ and it regenerates.   I have known many dogs in the same situation and they have done well.  It is the prolonged, high dose of pred that has caused Cushing's syndrome and if you take away the 'cause' the body will recover.  As your boy has been on preds for a long time, you cannot just stop it, even though it is a low dose. Certainly going to every other day dosing will immediately give his liver a rest on they day that he doesn't have preds and it will allow his own adrenal glands to kick in to provide the right amount of essential adrenal hormone for his needs. So the most important thing to do is to go to every other day preds and if a relapse occurs then ask your vet for a different immunosuppressive drug.  5mg pred is a very low dose for your boy's weight,  and whereas it is still contributing a little to the build up of steroid in his body it is not enough to stop a relapse of his disease if triggered so you have nothing to lose and everything to gain by reducing the dose and/or duration.

I do hope that once you have got him off the preds you will see a big improvement.

Jo



5
Yes Elaine, relapses can occur but if a dog has been off of steroids for a good period of time then remission has been achieved.

 For a relapse to occur, a trigger has to be met which destabilises the immune system again and causes it to attack its own body.  So as much as you can, limit the usual 'triggers' such as flea treatments, vaccinations etc., and limit as much stress as you can such as noise from fireworks, thunder etc.  The latter is very difficult to control.

I have had dogs that have had AI disease, and I have known many others,  that reach old age.  Sometimes relapses occur when they are younger, but it seems that the immune system can settle down over the coming years and some never have another AI disease again.  Limiting the triggers, I believe, is the best that you can do - and cross your fingers!

Good luck, and all the best.

Jo





6
Oh that is brilliant news. 

I am so chuffed that this long journey has achieved it's goal and Farley is back to being pred free and well.  UC Davis is an excellent veterinary hospital.

Thank you for letting us know, and thank you also for your kind words.   I am so pleased we could help you and Farely during these stressful times.

Fingers crossed!

Jo





7
Dear Elaine

Yes, if Woody starts to show significant clinical signs of his AI disease returning then he should be put back on an immunosuppressive dose of steroids, and if your vet agrees, to follow a protocol like Prof Day's.  There is no point in giving less than an immunosuppressive dose, or a shorter duration, because it won't work.

I would say a significant symptom is if the stiffness and pain, and high temperature returns then don't hesitate to put him back on the preds. The odd skin bump here and there might not be a good enough symptom to put him back on to an immunosuppressive dose. 

If you do have to start treatment again then I feel if it is caught in the bud, so to speak, he will respond well.

I hope  you don't have to go down that route again, but if you do then you have the experience now to deal with it.

Best wishes
Jo

8
In loving memory... / Re: For Pepper ‘My Sunshine’
« on: October 04, 2020, 10:25:50 AM »
Our thoughts and condolences are with you Brooke.

Pep will always be one of those special ones who will live on in our memory too.

Best wishes to you and the family.

Jo

9
Dear Elaine

That is such good news for Woody, and for you, and it is so lovely of you to let us know how he is getting on.  I am so pleased that we could help.  You have made my day!

Long may Woody continue to be well.

All the best

Jo

10
Hi Missy

An appropriate dose for natural vitamin E is: 400- 800 iu /12hours  Ref: Clinical Immunology of the Dog and Cat, 2nd edition, by Michael J Day.

There has been no established dosing regimen for EFA's despite them being considered 'steroid sparing' and an important addition to addressing skin disease.

The information by Yolande Bishop was given to illustrate just how varied the dosing is and its relative safety.

I would go by  Manual of Skin Diseases of the Dog and Cat, Sue Paterson's recommendation.

EPA 400mg/10kg
GLA 100mg/10kg

Jo


11
Hi

  It would be wise to get the steroids down to a low dose before any exploratory examination just in case they do a biopsy, as preds inhibit healing.  The other consideration is, anything like a GA  or even stress can trigger AI disease.  Having said that, you have to weigh up the pros and cons and sometimes you have to take the chance and go ahead with the investigation.  Have they been able to sample the discharge?

Jo

   

12
In loving memory... / Re: For Pepper ‘My Sunshine’
« on: September 26, 2020, 09:09:01 AM »
Oh Brooke,  I am so sorry to read about your dear Pep.  I also feel as if one of the family has gone.  I had got to know her so well and, a character such as Pep, one couldn't fail to love, even from this distance.  She is one of the most amazing dogs that I have had the pleasure to know.  Some animals are a cut above the rest.  I can't explain it but it is like they are on another level, and I always thought Pep was one of those. Despite her illness she was not going to be beaten and she was determined to leave before her time.  It is so hard for you, and you are right, they do take a piece of our heart with them. Making this decision, and saying goodbye to save suffering, is the most unselfish thing that we can do, and it is the hardest.  At times, I wish we had that option with human loved ones.   

It is so tough right now but in time, this pain will ease and the pain will be replaced by the wonderful memories and the pleasure of having a girl like pep in your life.  They give so much to us, and they are never forgotten.

My heart goes out to you Brooke.   Run free dear Pep. You will always be an incredible girl.

With love

Jo




 

13
Hi Missy

As Koda's faecal tests were negative, it may be that his gut is just out of rhythm.  I would ask your vet for some more metronidazole and only use it when the diarrhoea is a problem.  I have known many dog owners who ask their vet for some metronidazole when they go away on holiday, just in case their dog has diarrhoea, and very often only one or two tablets will resolve the problem. It is always good to have some in stock.  If there is no nasty gut bacteria then it is probably just about bringing a balance back into the gut.  I hope your vet will oblige.  The other thing that you could try is something like Prokolin:  https://www.animeddirect.co.uk/protexin-pro-kolin-advanced-for-dogs.

  or:  https://www.animeddirect.co.uk/dogs/healthcare/digestion?ad_brand=5577%2C5590%2C5579%2C5582%2C5591%2C     

Slippery elm is a natural product that you can try to combat diarrhoea see this link:   https://www.dogsnaturallymagazine.com/the-soothing-qualities-of-slippery-elm/ 

If Koda is on a low dose of pred then giving another gastroprotectant probably isn't necessary.  EFA's have to be given in high doses if they are to be 'steroid sparing'.  Take a look of the information below.  It is taken from my seminar notes for SLO ( an AI nail condition).  Unfortunately there is no established protocol for EFA's despite them being an important part of skin treatment.

I hope the above helps.

Jo

•   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
Essential Fatty Acid    Dosage differs with individuals   
EPA 400mg/10kg
GLA 100mg/10mg


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

14
Hi Missy and welcome

Reading your posting, you have done well with Koda over the last few years.  Certainly his clinical signs would suggest SLE because he had so many different systems affected.   It is not always possible to obtain a definitive diagnosis, especially with SLE, because a diagnosis of SLE is based on many different factors and systems involved.  Unfortunately, there is not one definitive test for SLE.   Having said all that, the treatment for SLE is the same as other inflammatory autoimmune diseases, and that is with immunosuppressive doses of steroids and very often a combination drug such as cyclosporine, mycophenolate, leflunomide, azathioprine etc....

If Koda relapses then you have no choice but to put him back onto immunosuppressive therapy.  Whether you just use preds and follow a good protocol such as Prof Day's, or whether you use a combination therapy probably depends on how Cushingoid he is at the time, resulting from the chronic use of preds.  If the Cushing's isn't too bad then he will probably be able to tolerate immunosuppressive doses of preds without the use of a different immunosuppressive drug.  The benefit of using a combination therapy is you will achieve sufficient immunosuppression to bring the disease under control but you will be able to reduce the preds (thereby reducing the Cushings symptoms) earlier than usual because you have the other drug backing up the immunosuppressive therapy.

One thing you might consider in addition to immunosuppressive therapy is, essential fatty acids (EFA) and natural Vitamin E.  EFA's are known as 'steroid reducing' because they are anti-inflammatory and natural Vit E (it has to be natural and not synthetic) is known to encourage new cell growth.  Both are excellent for skin and are used in conventional veterinary medicine to treat AI skin problems.  You can use sun block and perhaps purchase a cap for him to wear to protect Koda's nose and lips from the sun.

When a dog has been on preds for a while they are more open to infections and often there is a gut bacteria present, such as campylorbacter, salmonella etc.,  that may cause diarrhoea.  This may be addressed by giving antibiotics such as metronidazole.  Metronidazole also has the ability of slowing down the motility of the gut which enables more time for the water to be removed and lessens the diarrhoea.   When a dog is on preds for a long time and doesn't have a gastroprotectant, then gastric ulcers can form due to excess acid.  Often a sign of a gastric ulcer is excess bile and regenerative anaemia and dark stools, indicating a bleed. 

When a dog has Cushing's the liver has to work hard and it might be worth giving milk thistle, or SAMe or Denamarin. This will support the liver during this time.

Like you, I wouldn't do any invasive tests at this time.  Just treat the symptoms you are seeing.

Jo



15
Thank you for the update on His Lordship, Keeper!

Wow, he really knows how to keep you on your toes.  All I can say is, well done to you.  You are doing a grand job.

When my daughter's Cocker Spaniel got his repeated bouts of pancreatitis, she found the homoeopathic Iris Versicolor remedy to be of use and thought that it lessened, and shortened, the episode.  It might be worth trying next times you can see a pancreatic episode coming on.

Long may His Lordship continue to chase squirrels!

Jo



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