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Messages - Jo CIMDA

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1
Hi Kaajal

When you say bad poo, do you mean runny?  What colour is it? Is it blackish?  Is his Addison's being well controlled? 

If Diesel has diarrhoea then you must make sure that he is well hydrated. It could be, as Diesel is immunosuppressed, that he has picked up a bacteria so taking a poo sample to the vet might be a way forward, or ask your vet if he or she would treat speculatively and prescribe Metronidazole.  This is a very good antibiotic for gastric issues and it has the ability to remove water from the faeces as it passes through the gut, thereby making the stools firmer.   

Probiotics are also a good remedy for some causes of diarrhoea, and kaolin.  You can buy Prokolin from the internet without a prescription.  Meanwhile give Diesel very bland food and make sure he is drinking sufficiently, and if he isn't then syringe some water into his mouth if he has watery stools.

I hope this resolves very soon.

Jo




2
Medication, supplements and alternative treatments / Re: Fish oils
« on: January 18, 2021, 07:58:26 PM »
Hi Karen

Yes they can, in fact essential fatty acids have anti-inflammatory properties and are known as 'steroid sparing'.

Jo

3
Hello Kaajal

I have only just seen your last two postings.  Sorry.

Different laboratories have different reference ranges, so with this in mind, and assuming that the reference range that you have given is relevant to the lab that your vet uses, then the results are all within, or around about, the reference range and I would say that there is nothing for you to be concerned about especially if Diesel is not limping or appears to be in pain.   Good clinical signs suggests that the dose of Atopica is suppressing the immune system sufficiently enough to bring the IMPA under control.  This is particularly good because Diesel doesn't tolerate preds very well.  In fact the low dose of preds isn't doing anything to assist the IMPA treatment, but if Diesel is Addisonian then it is very likely that he will be needing a small replacement dose of preds for his Addison's disease. 

An article that you may find useful:

https://todaysveterinarypractice.com/oral-cyclosporine-use-in-dogs/

It seems as though everything is going according to plan and therefore I wouldn't be in a hurry to do anything drastic and the dose of Atopica can be reduced over time. 

I trust you will have a good meeting on the 19th. 

All the best

Jo


4
Hi and welcome

I am sorry that Bailey has IMPA.  The good news is, if it is treated correctly, and brought into remission, then she can lead a normal life again and without pain.  For a dog to have an autoimmune disease they have to have a genetic predisposition.  All is normal until a trigger is met and this induces an immune response that targets the synovial fluid within the joints.  No erosion of the bone occurs and once the immune system is brought under control the body can return to normal function again.  From now on you must limit as many potential triggers as you can.  I will copy some information below.

The correct dosage of steroids and the duration is crucial to the outcome.   The best protocol that I have come across is by Prof. Michael J Day and this can be confidently used as a guide.  If the dose is not high enough or it is given for a shorter duration than necessary you may see an improvement in the clinical signs, but the dog will relapse and not reach full remission.  Although alternative therapies may optimise a dogs condition none that I know of will bring the disease into remission.  Unfortunately, autoimmune disease has to be treated by conventional immunosuppressive drugs.
Below is some information taken from my seminar notes that I hope you will find useful.  A dog that has IMPA may relapse, and then treatment has to be started again, but I have known many IMPA dogs who have, after one or two bouts of IMPA, achieved long term remission and lived a normal, long life without any drugs. 
Best wishes

Jo


What You Should Know About Autoimmune Disease in the Dog
Genetics
It is known that autoimmune disease in the dog occurs in animals that are genetically predisposed. This means that they have an inherited risk of developing autoimmune disease.  It is thought to be a complicated mode of inheritance involving more than one gene; this is known as polygenic. Both parents carry the genes responsible and it does run in families, but this does not necessarily mean that if one dog in a litter gets an autoimmune disease the others will also follow.  This is possibly due to the different mix of inherited genes in individual pups in a litter, or environmental factors (potential triggers).  Unfortunately, at the moment, there are no DNA tests for these diseases.
It is not known why dogs with a genetic predisposition develop a specific autoimmune disease or indeed develop more than one autoimmune disease.  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.
Age
It is more likely to occur in a young to middle aged dog, but occasionally dogs as old as 14, or more, have been known to develop an autoimmune disease.
Gender
Females seem to be more prone - and this probably due to hormonal influences. Also, it is known that hormones can be a major trigger factor for autoimmune disease in the dog, as in humans. 
So, for a dog to develop an autoimmune disease it needs to have a genetic predisposition, but that’s not all, as it would have to encounter a `trigger’ that causes the immune system to malfunction.
So what are trigger factors?
Anything within your dog’s environment that may challenge the 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 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.   Reaction to chemicals, drugs or vaccines.
To sum up:
A primary autoimmune disease may occur if a genetically predisposed dog encounters a trigger factor that causes the immune system to become confused and mounts an attack on its own body parts or systems.
How do you control the immune system and get it to behave normally again?
Drugs, predominately steroids, are used to significantly suppress 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. 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. Some dogs will stay in remission without any drugs and others will have to be controlled on a low, every other day maintenance dose. 

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.

The Importance of Correct Treatment and Dosage

Iatrogenic Cushing’s syndrome may also occur if the vet has initially prescribed a dose too high for the size of dog being treated.  For example:  I received an email from the owner of an Irish Setter, with AIHA.  The dog was prescribed 200mg of prednisolone each day. I called the owner, only to hear that the dog had to be put to sleep that day.  I was not surprised. The poor dog was on nearly twice the highest, recommended dose of prednisolone.  She was 9 years old and had never had a day’s illness in her life.  What a terrible shock for the owners and what a lot of unnecessary suffering.  I know what it feels like because I too, have lost a dog due to prescribed overdosing of prednisolone.  The feelings of responsibility are enormous.
In contrast, some dogs are not treated with enough prednisolone.  Here’s another story:
A greyhound diagnosed with immune mediated thrombocytopenia (IMTP).  Her vet gave her an initial shot of dexamethasone (a steroid which is 6 times stronger in terms of glucocorticoid activity than prednisolone).  Some vets choose to give a shot of ‘Dex’ as an initial therapy in autoimmune disease, especially if the patient is acutely ill.  Its effects can sometimes be seen within 6 hours and lasts for 36-72 hours.
The vet did really well and a marked improvement in her clinical signs was seen. It is usual, 24 to 48 hours after the shot of Dexamethasone for the treatment to change to an immunosuppressive dose of prednisolone tablets and for the owner to continue treatment in the usual way.  However, the vet only prescribed 5mg of prednisolone a day. The owner said they were very concerned that after a few days of improvement, she seemed to be very poorly again.  The vet couldn’t understand why she was not continuing to improve.  He gave her another shot of Dexamethasone and the same improvement was seen.  I suggested to the owner that she either spoke to her vet about putting her dog on an immunosuppressive dose of prednisolone or change her vet.  They saw another vet in the practice, who was more experienced in treating autoimmune disease, and the dog was put on the correct, immunosuppressive dose of prednisolone and the treatment was successful.
These case histories demonstrate how important it is to treat promptly and correctly.

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.

A gastroprotectant should be given to protect the stomach from the excess acid that the steroid produce.

5
Hi Kaajal

I am sorry to hear that Diesel has IMPA on top of all the other problems.  I doubt that it is caused by anything other than an autoimmune response, so a primary IMPA. 

The most used, primary treatment for IMPA is immunosuppressive doses of prednsiolone eg., 1mg/kg/12hours.  A dog that weighs 28kg should be on a minimum of 28mg twice a day of prednsiolone, unless there is good reason not to.  The response to treatment is usually rapid - within 24-48 hours the dog is feeling so much better and not in the terrible pain that this AI disease causes.  10mg once a day isn't enough to significantly suppress the immune system to stop the destruction of the synovial fluid within the joints, so I would question why Diesel is on such a low dose.  Atopica can take up to a couple of weeks before the full effect is seen and even then it is not really used as a primary drug to treat IMPA, but it is a good secondary drug to use along side an immunosuppressive drug regimen of prednsiolone. What could be a consideration is to increase the pred dose to immunosuppressive for a few weeks, in order to control the immune system, and then the Atopica is at its full effect, reduce the preds.  You may be able to reduce the preds a little quicker then.

Alternative therapies can be other immunosuppressive drugs such as Leflunomide or mycophenolate.   Diesel may benefit from a gastroprotectant.   

Poor boy.  I do hope this is brought under control very soon and he starts to feel much happier and well again.

Jo

6
I am so sorry Karen.  The specialist vet will know exactly how to treat this, so you have done the right thing by going to those in the know.

Wishing Pippa and you all the best,  and just tell yourself that this is the only way and she will ultimately benefit from the treatment.

Jo


7
Hi all

What a terrible year it has been for so many people around the world.  Despite this, with or without your loved ones present, I do wish you and your dogs a very happy Christmas and we can only hope that next Christmas will be much improved.

Best wishes to you all, and to your beloved dogs.

Love
Jo
xx

8
Hi Karen

I am so sorry that Pippa has aspergillosis.  I am sure that you have done your homework, but just in case you have missed these they might be interesting for you to read.   I don't know a lot about aspergillosis but if the diagnosis is correct the treatment can be harsh.  I would say that it is because of Pippa's weakened immune system that this opportunistic fungus has taken hold.

Ask the vet if there is anyway that it could be treated with oral anti-fungal drugs without having to go down the invasive route.  It is worth trying just in case it works.

https://www.dvm360.com/view/when-consider-aspergillosis-dogs

https://vcahospitals.com/know-your-pet/aspergillosis-in-dogs#:~:text=Treatment%20of%20systemic%20aspergillosis%20Treatment%20is%20difficult%20for,to%20its%20high%20potential%20to%20cause%20kidney%20damage.

https://www.dvm360.com/view/review-selected-systemic-antifungal-drugs-use-dogs-and-cats

I do hope they can treat it with oral drugs.

All the best

Jo

9
Our dogs' stories. / Re: My 19 month old Bearded Collie
« on: December 23, 2020, 11:47:45 AM »
Hi and welcome

I am sorry that your young boy has an immune mediated condition.  Even if there is no definitive diagnosis, for the majority of inflammatory AI diseases the treatment is the same, and this is with immunosuppressive dose of prednisolone, and sometimes with a combination of another immunosuppressive drug.

I shall copy some information below and I hope this will give you a better idea of what to expect from the treatment.  A good treatment protocol is essential if the disease is to achieve remission.   The best protocol that I have come across is by Michael J Day and it can be confidently used as a guide.  A gastroprotectant is also essential to protect the stomach from excess gastric acid that can be produced when a dog is on steroids.

If you feel you need more specialist help then Glasgow Vet School is among the best in the country.

If there is anything that you are not sure about, please ask.

Best wishes

Jo


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.

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.
The Importance of Correct Treatment and Dosage
Iatrogenic Cushing’s syndrome may also occur if the vet has initially prescribed a dose too high for the size of dog being treated.  For example:  I received an email from the owner of an Irish Setter, with AIHA.  The dog was prescribed 200mg of prednisolone each day. I called the owner, only to hear that the dog had to be put to sleep that day.  I was not surprised. The poor dog was on nearly twice the highest, recommended dose of prednisolone.  She was 9 years old and had never had a day’s illness in her life.  What a terrible shock for the owners and what a lot of unnecessary suffering.  I know what it feels like because I too, have lost a dog due to prescribed overdosing of prednisolone.  The feelings of responsibility are enormous.
In contrast, some dogs are not treated with enough prednisolone.  Here’s another story:
A greyhound diagnosed with immune mediated thrombocytopenia (IMTP).  Her vet gave her an initial shot of dexamethasone (a steroid which is 6 times stronger in terms of glucocorticoid activity than prednisolone).  Some vets choose to give a shot of ‘Dex’ as an initial therapy in autoimmune disease, especially if the patient is acutely ill.  Its effects can sometimes be seen within 6 hours and lasts for 36-72 hours.
The vet did really well and a marked improvement in her clinical signs was seen. It is usual, 24 to 48 hours after the shot of Dexamethasone for the treatment to change to an immunosuppressive dose of prednisolone tablets and for the owner to continue treatment in the usual way.  However, the vet only prescribed 5mg of prednisolone a day. The owner said they were very concerned that after a few days of improvement, she seemed to be very poorly again.  The vet couldn’t understand why she was not continuing to improve.  He gave her another shot of Dexamethasone and the same improvement was seen.  I suggested to the owner that she either spoke to her vet about putting her dog on an immunosuppressive dose of prednisolone or change her vet.  They saw another vet in the practice, who was more experienced in treating autoimmune disease, and the dog was put on the correct, immunosuppressive dose of prednisolone and the treatment was successful.
These case histories demonstrate how important it is to treat promptly and correctly.
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.

10
Hi Melissa

That is good news. 

I have not used apoquel myself but I know it is a popular product for the treatment of allergies.    I would do some homework so that you are aware of the side effects and just watch out for any.  This article may be useful to you. 

https://www.petdermatologyclinic.com/apoquel-information

There are other drugs that can be tried, so if you have any problems get back to your vet and ask for an alternative.

Good luck -  fingers crossed.

Jo

11
Hi Melissa

If Koda's bloods were good in September then forget his age and treat him as you would any other dog.  Some old dogs are not as healthy as some old dogs, so armed with blood results treat what you see.  It would be unusual for an older dog not to have some stiffness or arthritis in the hind legs, so again I wouldn't worry about that either.

If it is mainly a skin problem then it isn't SLE.  SLE affects many different body symptoms and it does not isolate to just one. So this may not be an AI disease at all.  It may be an allergic reaction, or it may be a fungus, bacterial or parasitic problem.  Your vet may be able to assess and give speculative treatment without having to do extensive tests.  It is worth a try anyway.

So forget Koda's age and just look at what needs treating and go for it.

Jo

12
Hi

I am sorry Koda is showing these signs.  If you are sure (or as sure as you can be) it is a relapse of the AI disease then his system has to be suppressed in order to control the immune system which is doing the damage.  However preds is just one immunosuppressive drug and these days you do have choices.  The Doxy won't address any symptoms of polyarthritis so you will probably have to go for a different sort of immunosuppressive drug such as cyclosporine, leflunomide, mycophenolate to mention a few.    Perhaps, especially as he is almost 12 years old,  a full blood test to see how his organs are at present might be good idea, and the results may help your vet to make a decision about which drug to try next. A good article about different immunosuppressive drugs:

https://www.dvm360.com/view/immunosuppressive-drugs-beyond-glucocorticoids

A lower dose of preds with a 'combination' drug might work for him and this will avoid severe Cushing's symptoms. If his skin is continuing to get worse then you do need something to halt the destruction. I would take Koda back to the vet and have a chat.  He is not too old for remission.  It just needs the right drug/s to control the 'out of control' immune system.

I hope you can start him on something very soon.

Jo

13
Hi

It is good that your vet has given the correct immunosuppressive dose. If the dose is reduced too soon then it is most likely that a relapse will occur.  The idea is to give the starting dose enough time for it to bring the immune system under control so that when you reduce the dose, and continue to reduce over a period of time, remission will be reached.  If the dose is reduced too soon and a relapse occurs then the dose will have to be put back to an immunosuppressive dose and you will have to start all over again, but this time there will already be a build up of glucocorticoid in the system and the side effects may become too much.

Yes other AI diseases can occur and some breeds are more prone to particular AI diseases, but that doesn't mean that a different AI disease can't be triggered in a genetically predisposed dog.

I do hope he is improving.  The protocol below is the best guide.  The longer you can leave it before reducing, say to 18-21 days the more likely the immune system will be sufficiently suppressed to return to normal function once it is released again when reducing the  preds. 

Jo

14
Hi

I apologise for the delay in replying to your post.

If your girl does have IMPA, or even if your vet treats speculatively for IMPA then the dose of sterouids (prednsiolone) has to be immunosuppressive and that is 1mg/kg/12hours.  This is the best immunosuppressive protocol I have come across and it can be confidently used as a guide.


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.

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.

I do hope that you vet will work with you, and if needed, increase the pred dose to an immunosuppressive dose.

Best wishes
Jo

15
Hi and welcome

I am sorry that your Vizsla is unwell.  The Vizsla breed can be genetically predisposed to immune mediated/autoimmune disease.  See this website:   https://www.vizslahealth.net/

A definitive diagnosis is not always possible, or necessary, especially is speculative treatment has started and an improvement is seen.   The main concern now is, assuming that this is an autoimmune disease the dose of steroids is crucial to the outcome and I I don't know how much your boy weighs but 25mg of prednsiolone doesn't seem like an immunosuppressive dose which should be 1mg/kg/12hours.  Any less than this dose will not achieve long term remission, and much more than this dose will produce unnecessary side effects.  This is the best immunosuppressive drug protocol that I have come across and it can be confidently used as a guide.

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 do hope that you vet will work with you, and if needed, increase the pred dose to an immunosuppressive dose.

Best wishes
Jo

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