CIMDA

Apologies for anyone who has not been able to access the website.

 It was temporarily down but it should be up and running again now.

Jo

Hi

At 11%, your vet should be seriously considering a blood transfusion now to buy time. 

If it is non-regenerative anaemia then it will take at least 5 days to see any improvement, and that is if the pred dose if significant enough and if her bone marrow is able to produce .  It can take up to one month for the bone marrow to kick in.

I do hope your vet will take advice from somewhere like the Royal Vet College or Langford, Bristol.  They are always happy to advise.

All the best

Jo

Hi

The name Prof Michael J Day should be familiar with all vets because he was such a well respected pioneer.  Sadly, he passed away nearly two years ago but his legacy, in so many areas to do with immune mediated disease and vaccination, lives on.  I do hope the vet will work with you.  The Willows have a good reputation but I have found lately that not all specialist vets know how to treat inflammatory AI diseases.

Fingers crossed.

Jo

Hi Vanessa

I do hope Odin is getting on and improving now that the Addison's treatment has started.

It is a steep learning curve for sure - for you and your vet!  Always keep a couple of 5mg prednsiolone in your pocket when you are out for a walk, just in case he needs that boost.

Jo

Hi Erica

I do hope Elsie is starting to improve.  One thing that alarmed me is the mention that she was on Metacam and also prednisolone.  These two drugs are not compatible and if a dog is on prednsiolone they should not be on any non-steroidal anti-inflammatory drug.  Please do not give Metacam whilst she is on pred.  The combination will really upset her tummy and increase the risk of stomach ulceration.

Jo 

Hi Erica and welcome

I am sorry that Elsie is not well.

Typical symptoms of SRMA is pain, high temperature and a stiff neck.  This is diagnosed by doing a spinal tap.

An AI disease with similar symptoms to SRMA  (pain in joints, high temperature but without the stiff neck) is immune mediated polyarthritis and taking synovial fluid via joint taps is the diagnostic procedure for this AI disease. 

The vets have concluded that it is likely that Elsie has an inflammatory AI disease then the treatment is the same regardless of a definitive diagnosis. 

You should not give Omeprazole within one hour of giving other medication, and if you want to give it before other meds then you should give Omeprazole two hours before.   So give Omeprazole two hours before or one hour after other meds.   This is so that Omeprazole doesn't inhibit other medication.

If Elsie weighs 10kg or thereabouts, then 20mg is the correct dose, whether you give it once a day or split the dose and give it every 12 hours.  The reason for splitting the dose is it is easier on the stomach. However, when treating a young dog or puppy for an inflammatory AI disease because their metabolism is different to an adult dog this can also affect how they metabolise drugs and if the response is not as expected then very often the dose of steroid has to be increased. 

Another consideration:  Whippets, or sighthounds, often respond differently to medication and whereas one would expect a dog to be hungry and put on weight when on immunosuppressive doses of steroids, I have known many Whippets to lose weight and respond very differently and this maybe due to a different metabolism to other dog breeds.   So there are a few considerations because she is young and because she is a Whippet.

The prognosis for either primary IMPA or SRMA is very good.  The correct dosage is crucial to the outcome and to achieving remission.  It is not unusual when a young dog develops SRMA or IMPA that they relapse, so don't be surprised if this happens when the steroids are reduced.  Having said that, if you have a good immunosuppressive drug protocol    then there is a good chance that she will not relapse.  I have known many dogs to achieve long term remission first time. 

Below is an excellent immunosuppressive drug protocol and it can be confidently used as a guide and tailored 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.

I hope Elsie starts to improve very soon, if not then return to your vet for a review of her meds.

Jo

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.

 IMPA - Immune Mediated Polyarthritis
Primary Immune mediated polyarthritis is the most common non-erosive polyarthritis in the dog. IMPA can be primary, or secondary to other diseases such as SLE, myositis or meningitis. Symptoms of IMPA can closely resemble Lyme disease or multiple joint infection and this has to be considered in the differential diagnoses.
For a confirmed diagnosis of IMPA, joint taps need to be performed to obtain evidence of infiltrating immune cells within the synovial fluid in the joints.   Clinical signs such as shifting lameness, soft tissue swelling around the joints, difficulty in rising to a stand, stiffness in the neck and back, and very high temperatures etc., can be vague and evident for several months prior to diagnosis.
Clinical signs therefore can be intermittent and initially antibiotic and non-steroidal anti-inflammatory drugs are usually given, but little improvement is seen. The disease continues to progress until the dog becomes quite overcome by the inflammatory process. Also, it is not unusual for the dog to become depressed and anorexic and stand with its head held low, unwilling to move. This is a very painful condition.

Steroid Responsive Meningitis Arteritis
Not to be confused with bacterial meningitis.
SRMA is inflammation of the meninges (membrane covering the brain) and peripheral nerve roots, caused by immune mediated infiltration via the spinal cord.  The disease may acute or chronic and is cyclic in nature.   Relapse is not uncommon.
Clinical signs:
High temperature (up to 42C – 107.6F)
Neck and joint pain with stiffness.
Depression.
Diagnosis:  Evidence of immune cells via spinal tap and clinical signs.
Treatment:  Immunosuppressive doses of Steroids

Hi Ann

For a French bulldog, Henri is having more then enough pred to support his cortisol levels. The physiologic dose is 0.1mg/kg once a day (Plumb's Veterinary Drug Handbook 8th Edition) but of course at times of stress it is necessary to increase that dose.  Perhaps the levels of cortisol are a bit too high at the moment? It is difficult to know what to do because if his body is under stress due to the instability of his potassium then he may need extra cortisol??

Sickness and diarrhoea would suggest that he needed his next shot of DOCP.  I do hope that the sickness stops now.  DOCP must be tailored to the individual- as you are doing - but if this continues I wonder if a change to f-florinef might be an option?  Again many questions.

 Perhaps next time that they take blood, have a full biochemical, and complete blood count done to see if there is anything else that might give a clue as to what is going on.

Jo