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Messages - Jo CIMDA

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1
Hi and welcome

I am sorry that your Sheltie has IMHA.  Was the original anaemia non-regenerative (destruction occurring in the bone marrow) or regenerative anaemia where the destruction of the red blood cells is most often happening in the spleen or liver?

My first instinct is that further immunosuppression is not needed because the HCT is only just below the reference range, so at this time the bone marrow is regenerating.   It is very reasonable to think that if the HCT is not increasing then more immunosuppression is needed but this is often the opposite of what is needed when a dog has been on high doses of preds for a longer period than usual. 

I have known several dogs to have been on immunosuppressive/high doses of prednsiolone for an inappropriate extended period of time (ie., longer than 3-4 weeks) and the weeks pass and the dog continues to be on a high dose of preds, this has caused the HCT to plateau.  I cannot say exactly why this occurs but in cases like this, when the pred is reduced the HCT starts to rise and normal levels are achieved. It may be a decreased release from the bone marrow as is seen with lymphocytes and eosinophils.

I notice that he is also on Nexium to protect his tummy from the excess acid that the preds produce.  Was he put on this at the start of treatment?  If not, was he put on this because he developed bleeding gastric ulcer, which would cause regenerative anaemia?

I presume your boy is also showing signs of drug induced Cushing's eg., pot belly, muscle weakness, hair loss thirst, hunger etc.,  These adverse signs should not be ignored and the medication should be reduced.  When treating something like IMHA with immunosuppressive drugs, and in particular prednsiolone, all clinical signs, including adverse effects of the drugs, and the blood results should be considered when making decisions about medication and dosages etc.  The good news is the side effects of preds do not affect smaller dogs/animals as badly as larger dogs.

 'The goal of therapy is to use as much as is required and as little as possible for as short an amount of time as possible'.  Plumb's Veterinary Drug Handbook, 8th Edition. 

Personally I don't think added immunosuppressive treatment is necessary as your boy is also on Mycophenolate, and this should be providing sufficient immunosuppression, and a dog must not be on prednsiolone, especially at high doses for a very long time.   All immunosuppressive treatment dosage is designed to be reduced over a period of time. 

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.

I hope this information helps

Jo


 Taken from my seminar notes:

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.

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. 

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.
Notes:
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.






2
Hi and welcome

I am sorry that Fergus has non-regenerative anaemia.  Unfortunately this is a known inherited condition that can be seen in beardies. 

Catherine has given you the information that you need, so there is not a lot more than I can add,  just to reiterate that Fergus should be on 1mg/kg/12hours prednisolone and it is best to give a low fat diet and give perhaps four smaller meals than one or two larger ones.  This makes it easier for this pancreas to deal with and may prevent pancreatitis.  Also, as far as I am concerned, there is no good reason not to give a gastroprotectant because if it isn't given there is a risk of the stomach becoming ulcerated and  if an ulcer develops then it may bleed which will cause regenerative anaemia.    As Fergus' immune system is significantly suppressed you should be careful about taking him to a popular dog walking area where he may pick up infections.  Often a course of antibiotics is given at the start of treatment as a precaution. 

I do hope Fergus  is starting to feel better. 

Jo

3
Hello and welcome

I am so sorry for your loss, and I do hope that get the additional information that you need from the stories on this site.

Best wishes
Jo

 

4
Hi

Clumping can be caused when the blood is taken.  The red blood cells and platelets can get damaged through the vacutainer blood collection tube.  Taking blood with a larger tube and from the jugular may avoid damage to the cells. If there is clumping then the actual count is always much higher.

All the best
Jo

5
Hi Jane

I am sorry that you have the need to post again, although it is always good to hear from people.

There are two major/common causes of thrombocytopenia. Has the specialist ascertained whether the low platelets count is because the bone marrow isn't producing enough or if there is a destruction of platelets within the spleen/liver etc.    As this seems to be a reoccurring problem for Archie, I do think that this needs to be established because it could determine the right, necessary treatment. 

If the destruction is within the spleen then often the removal of the spleen rectifies the problem.  Supportive treatment such as blood transfusion may be necessary during and just after the operation if the platelets are very low.  Alternatively it would be prudent to get the platelets to a good level before surgery, if that is possible.   With this sort of IMTP the platelets can remain low and not get to the stage of bleeding and bruising because the bone marrow is still able to replace the destroyed platelets, even at a lower level than normal.

If it is a primary autoimmune cause and the bone marrow isn't producing any immature platelets then it is immunosuppressive treatment but as Archie has been on steroids for a considerable length of time, it would be prudent to consider a 'combination' immunosuppressive drug such as mycophenolate mofetil.  So9 I would put this question to the specialist and depending on his answer, perhaps a new plan of action can be made.

What breed of dog is Archie.  Some breeds such as greyhounds and whippets can have  naturally low platelets and this is not a problem to them.

I do hope you manage to have a good chat with the vet to see how you can move forward and keep Archie stable.

Jo

6

Hi all
I have a 6-month-old rottweiler dog named Zeus. I love him so much, we spend so many good times with him. There is nothing wrong with his health at the moment. I hope that all lives in poor health will recover as soon as possible.
I have a question for you, Zeus is my first dog, so I don't have much experience in these things. What are the health problems of Rottweiler dogs..?

Hello/Bonjour

I do not speak French but I have managed to translate your posting into English, see the  above text.

I am sure there are other websites in French but you may find this one interesting.  http://www.vetstreet.com/dogs/rottweiler

All I can say is in more than 20 years of dealing with autoimmune disease in the dog, there have been very few that have come to me with an autoimmune disease.

Best wishes
Jo


Je ne parle pas Français j’ai réussi à traduire votre message en anglais, voir le texte ci-dessus. Je suis sûr qu’il ya d’autres sites Français, mais vous pouvez trouver celui-ci intéressant. http://www.vetstreet.com/dogs/rottweilerTout ce que je peux dire, c’est qu’en plus de 20 ans de traitement de la maladie auto-immune chez le chien, il ya eu très peu qui sont venus à moi avec une maladie auto-immune.

7
Hi Julie

You were so lucky with your first vet.  Changing over suddenly to Zycortal threw everyone into confusion. It wasn't fair on the vets, the owners and definitely not fair on the Addisonian dogs who were being well controlled on F-florinef.   It was a disgraceful thing for the drug company to do and I knew some dogs who didn't survive the transition.

5 years on, the vets should know better, but of course Addison's disease is not seen, or diagnosed often in general practice and the GP vets don't have the experience, and in my experience Dechra are not the most helpful of companies.

I totally agree with you, the K:Na ratio is what I would look at first and then the individual values if there was some concern.  Just looking at the separate values of K and Na, in my opinion, does not take into consideration how the individual patient processes and utilises the replacement hormones.  Hormone replacement therapy is always tailored to the individual, taking into consideration the clinical signs as well as the blood results, and of course ageing.  If the ratio wasn't important  then why, historically,  would it have been such a key indicator in diagnosing and treating Addison's disease?   If the ratio is higher than around 32 then I believe the next dose of Zycortal should be delayed.   I have known some dogs go to over 60 days before the next dose was necessary but that was in the early days of Zycortal.

The reason why I asked about a high temperature and swollen joints is Jetta has a genetic predisposition to autoimmunity and when a dog has had one AI disease there is a chance that they will get another (as with Jetta), so the weakness could have been something like IM polyarthritis or IM myositis, but Jetts'a weakness does seem linked to her hypoT and Addison's and nothing more, and that is good news.

 Thank goodness that you are on the ball!

Jo


8
Hi Julie and Jetta

Hormones are such tricky things because they can have a knock-on effect on each other, and sometimes one problem at a time needs to be addressed as opposed to looking at the whole picture.   Also, just because a dog is getting on a bit in years, vets shouldn't think that she is 'an old dog'.  Her blood results and physical health may be better than a dog half her age.  Of course age may play a part, but it doesn't always.

It is acceptable, and can be normal for some, when a dog is on thyroid hormone replacement therapy for the level to be up to 25% above the reference range, and as a dog gets older the dosage sometimes has to be altered according to the clinical signs, so the increase in thyroid meds back to a higher dose seems the right thing to do, and you have seen positive results too, which is good news. The slight increase in weight, and perhaps lethargy and other typical signs of a low thyroid could certainly have been down to the less than ideal dose of Thyforon.  At least, for now, you can take the thyroid out of the equation.

As for the Zycortal, Jetta has done really well to have come off of F-florinef and on to Zycortal without any major problems but again, as dogs get older sometimes the dose may have to be altered according to the blood results and clinical signs. It is also possible that a lower than ideal thyroid level may have had an affect on how the Zycortal is tolerated/used/metabolised etc.  What is her usual sodium and potassium ratio K:Na at day 28, just before the next injection is given? 

The majority of dogs that were started on the ridiculously high dose of Zycortal that the drug sheet still recommends have, over time, been reduced to a much lower level and some dogs that I have known have been stable at  levels 0.5ml every 28 days.  Unfortunately, despite the science, it is often a 'suck it and see' situation and the dose and duration has to be tailored to the individual. I wonder if it is worth checking with the manufacturer if the batch of Zycortal being used is stable and efficacious?

As far as I know F-florinef is still available in Europe but depending on where you live the export to some countries may be impossible.  The generic name is fludrocortisone acetate and this should still be available as an extra label drug.

Now that you appear to have a better result by increasing the dose of Thyforon back to where it was,  perhaps this will allow any remaining symptoms to show a clearer picture of what might need tweaking.   Lots of Addisonian dogs need less than the recommended dose of pred too, so if you and your vet are happy with the thyroid blood results, and the improvement of other clinical signs that are associated with hypothyroidism; and the if the correct Zycortal dose is established and her Addison's is stable, if Jetta still has symptoms of weakness then look at whether the pred need to be reduced and the pred dose optimised.  This can be reduced very slowly over weeks  by 0.5mg reductions to see if it makes a difference.   

Does Jetta have a temperature, are her leg joints warm to the touch, and does she seem to be in pain when she tries to get up?

Jo





 

9
Hi and welcome
I am sorry that your GSD has autoimmune problems.  When treating AI diseases with prednsiolone the dose and duration is crucial to the outcome, so it could be that the drug protocol that she has been on was not ideal.  It is best to treat with immunosuppressive doses of prednsiolone and follow a good protocol so that the dog is only on steroids for as short a time as necessary.  I don't know what dose of preds she is on now but being on preds for one year is a very long time and the side effects can become a problem.

Some autoimmune disease skin diseases can be treated without the use of steroids.  The most popular treatment for AI skin disease, such as discoid lupus or SLO (an AI disease that affects the nails) is something called Doxycycline, with the addition of niacinamide.  Most dogs tolerate this well.

It would be prudent before changing drugs to have a full biochemical blood test and a complete blood count done, just to make sure that her liver etc., are coping with the drugs.  It is likely that if she has been on preds for a year that she has drug induced Cushing's syndrome, and this will cause muscle weakness and also some skin problems due to the side effects of the preds and the skin becoming thin.  Long term use of preds can also cause skin crusting and lesions called calcinosis cutis.   So the effects that you are seeing may be as a result of her being on long term preds and not an AI disease,  and this has to be established before starting on other therapy.  You may also think about adding essential fatty acids to her regimen and Natural vitamin E, because this encourages new cell growth and  the EFA's repair the skin and have an anti-inflammatory effect known as 'steroid sparing effect'.

There are other immunosuppressive drugs but I do think that you have to be sure that the clinical signs that you are seeing is an AI disease before starting her on a new drug.   If the clinical signs are due to the prolonged dosing of preds, then if you reduce the preds you might see an improvement in her skin, her muscle weakness and in time a big improvement in her coat.

Important note: (preds must not be stopped suddenly otherwise an adrenal crisis could occur)


Have a chat with your vet about the above and if your vet doesn't respond to your concerns, then have a look around for a vet who will work with you. Sometimes you have to change vets for a different opinion and a fresh look at the problems in front of you.

Jo




10
Good luck. Hoping you will see an improvement very soon

Jo

11
That is fantastic news!!!!

Thank you for the update.

Jo

12
Hi and welcome Mickey's mom.

I am sorry that your Mickey is having these problems.  I am a big fan of supplements, and some alternatives to conventional veterinary medicine but I have to acknowledge that a dog with an autoimmune disease  often needs conventional drugs to significantly suppress the immune system in order to bring the disease under control and into remission.   

It is not always necessary to give immunosuppressive doses of prednisolone for some autoimmune skin diseases such as discoid lupus  (DLE) and symmetrical lupoid onychodystrophy (SLE,) but if the AI disease is life threatening or it  needs to be brought under control quickly such as pemphigus, then immunosuppressive doses of prednsiolone is extremely effective.  It does, however, have to be given in the correct dose and for the correct duration to have any lasting effects and to achieve remission.  The immunosuppressive protocol that has already been posted by Catherine is the best protocol that I have come across and it can be confidently used as a guide.

It is much better for the poorly dog to put them onto  a good drug protocol than to go on for many weeks without achieving remission in an attempt to avoid using immunosuppressive drugs.   If Mickey does have an autoimmune disease then it would be better for him to go onto a good protocol with prednsiolone and taper off over a period of a few months than to give something that will not fully address the problem, and the immune destruction of the skin, that is causing ulceration, will just continue and get worse. 

If you wanted to avoid the use of steroids then you might try a treatment of doxycycline and niacinamide with the addition of Natural Vitamin E and essential fatty acids.  This treatment could take 9 months or more but it may work, depending on the sort of autoimmune skin problem that he has. Even if you go down the steroid route you might consider adding EFA's, because this does have an anti-inflammatory effect after a while, and is known to be 'steroid sparing',  and Natural Vitamin E as this encourages new cell growth, but it has to be the natural form because the synthetic form is not effective.

Have a chat with your vet and don't be put off by using conventional drugs, but be sure that it is the correct dosage and the protocol is a good one.

Jo

13
That is great news. 

Very often you have to go through the crisis to get to the other side.  Of course it helps if the drugs are correct and being well controlled and tolerated, but those anxious moments are inevitable with some AI diseases.

Fingers crossed for Charlie now.  Thank you for the update.

Jo

14
Hi

Prednisolone can affect the absorption of calcium in a growing pup and this maybe why your vet is being cautious, and I understand that,  however, if a dog has a life threatening autoimmune disease then the risks and benefits have to be considered and the best treatment, dosages and duration has to be decided on. 

Lets hope that the current protocol that Tucker is on will do the trick.

Jo

15
Hi

You do need a vet who will work with you.  Catherine has said it all, and I can't add any more, only to say  that you either go with your vet and follow her instructions or find another vet.  Your vet's protocol may work, but there is no way of knowing until you try.  We can only advise you of our experiences but ultimately it is the responsibility of your vet. I would ask her the reasons for reducing the preds before the PCV is within normal range, and ask her what the likelihood is of a relapse. 

Jo

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