CIMDA

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

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

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
 

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

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

Hi Erica

I wonder if Elsie may have an inflammatory gastric problem such as IBD.  I wonder if your vet would consider a short course of metronidazole to see if it has any good effect?   Metronidazole can also kill off any nasty bacteria.

Quote:  Plumb;'s Veterinary Drug Handbook 8th Edition

For adjunctive therapy of inflammatory GI conditions (IBD)

(extra label)  10-15mg/kg twice daily.


This is a very widely used drug in veterinary practice, and I have known many dogs' to benefit from its use.

It might be worth a try.  What do you have to lose?

Wish you luck

Jo

Hi Erica

Just wondering how Elsie is doing and if the vet has managed to give something to settle her tummy?

Jo

Hi Erica

From the symptoms that you describe it does seem as though Elsie has some sort of gastric issue.   I hope the Omeprazole sorts it for her. Ranitidine isn't used anymore.

 Another consideration would be pancreatitis.  See how things go and certainly get back to the vet if there is no improvement.   

The low white blood cells could be what is called a 'stress leucogram' and this is very non-specific but it does indicate that something is not quite right.

 A stress leucogram is when the neutrophil numbers are high-normal to increased and the eosinophils and lymphocytes are low-normal to decreased. These are all white blood cells.

Yes, it is perfectly fine to stop the prednisolone.  The weaning down process has been very slow and with a dose of 1mg every other day there is no problem in stopping it altogether.

If she is still eating, then make sure that it is a low fat diet and better to give more smaller meals than just a couple of big ones.

I do hope that she improves very soon.

Best wishes
Jo

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.




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. 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 'combination' immunosuppressive drug.  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, or similar, is given to coat and protect the stomach. Another common gastroprotectant used is Omeprazole.
Note: Gastroprotectants must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed
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 addition of a 'combination' therapy immunosuppressive drug is very useful. 
All drugs carry side effects, but they do not carry the same side effects as prednisolone, therefore by using a secondary drug, in combination with prednisolone, the symptoms of iatrogenic Cushing's syndrome can be minimised.  Some 'combination' immunosuppressant drugs as Azathioprine or cyclosporine, take at least 10 days to take effect, so 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.  The advantage of using a secondary drug like Mycophenolate Mofetil alongside prednisolone, is that it starts to take effect within 4 days and this can make all the difference. 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.