CIMDA

Hello Monica

Ripley needs to show a good response and I hope this will improve over the next couple of days. 

It is difficult for me to comment on your vet's experience, and perhaps he has a point.

You know the immunosuppressive dose of Cyclosporin given in the Plumb's Veterinary Drug Handbook.  I can't challenge your vet when he has successfully treated a dog with 50mg/kg per day.  The dog was due to be euthanized so there was nothing to be lost by trying a large dose - and it worked!

 The relative glucocorticoid activity of dexamethasone is 6 times greater than prednisolone, and the duration of biological effect is: 
Prednisolone 12-36 hrs and Dexamethasone 36-72 hours (Canine Medicine and Therapeutics by Neil Gorman) so I suppose it depends on what dose of Dex your vet is giving.

Have a thorough discussion with this other vet tomorrow and come up with the best plan for Ripley.  All dogs are individuals and must be treated as such.  What works for one won't necessarily work for another.  Also, the vet must take into consideration the blood results the response to therapy and most importantly the side effects of the drugs that you are seeing at that time.

All the best and good luck with the vet. 

Jo

Hello Jo

Ripley did get better, but she is not well, I could say she looks like slowly recovering.
Her paws are still warm, and therefore inflamed, and she is lame mainly in the morning. She usually lies on her couch, even if she stands up more often than before.

Anyway, I have just found out, to my horror, that the shot the vet gave her was 1.5 mg, not immunosuppressive dose but just anti-inflammatory, that's why maybe he decided to do it for three days! So, all in all Ripley is very well I can say.
I will start tomorrow with Prednisone at 35 mg again (which I gave to her on Tuesday, when she actually did get better) and see what happens.

I will talk with another vet tomorrow, we saw him a while ago when Ripley was getting better, and maybe he can help us more.
We need someone who is ready to learn and study things they don't know, because this is a very rare condition, so not all the vets are prepared.

This is really wearing me out, I would like so much to help my lovely dog, but there's only so much I can do

I will keep you posted.
Thanks
monica 

Hi

2.5mg a day from 40mg is absolutely great.  Do you intend on going to every other day for a while before stopping it altogether?   It is a low dose but taking it slowly at the end often brings good results. 

 I don't know any reason why you can't feed Lenny on a good quality raw food, although I doubt many vets will agree.  If you are in the UK you can contact a vet called Nick Thompson.  Nick is a consultant for some raw food companies and he will be able to advise you of the best one to go for.  He is a lovely guy and he really cares. I believe you can have a telephone consultation.

 http://holisticvet.co.uk/

Good luck with this and let us know what food you decide to give Lenny.  It might help others.

Jo

Hi Jo

Lenny is continuing to do well and is now down to 2.5mg per day from 40mg.  Prior to him becoming poorly he was on a raw diet, but has been on wet food whilst on steroids.  It doesn't really agree with him, so once he's off the steroids I really want to put him back onto a raw diet.  Do you know of any reason why I shouldn't do it?  Thank you.

PS I purchased an air purifier.  No success as far as Lenny is concerned, but the air feels nice and fresh  .  I will try anything I can to help him.

Hi

It is good to know that Puddles is doing well. 

The skin problem Puddles has on the back of her neck is a common site for drug induced calcinosis cutis and is a result of the prednisolone she has been receiving.   Not all dogs get it but it is common in drug induced Cushing's.  See this extract:

https://en.wikivet.net/Hyperadrenocorticism

Cortisol stimulates protein catabolism for gluconeogenesis so patients exhibit muscle weakness. Protein catabolism and weakness gives poor wound healing. Collagen damage due to protein catabolism allows the deposition of calcium in the skin. Calcium acts as a foreign body producing a granulomatous reaction. This is called Calcinosis Cutis.

Other good links:

http://todaysveterinarypractice.navc.com/dermatology-details-dermatologic-markers-of-internal-disease-in-dogs-cats/

The most common underlying cause of calcinosis cutis is hyperadrenocorticism—either endogenous or iatrogenic Cushing’s disease. Additionally, metastatic calcification can occur in dogs or cats with chronic renal failure.3

http://www.vetbook.org/wiki/dog/index.php/Calcinosis_cutis

When a dog is on high doses of steroids for a prolonged period of time, in addition to the calcium deposits,  the skin barrier starts to break down and this is when skin lesions start to show.

 Puddles is on the reducing dose of prednisolone now so it would be a good idea to start giving her Natural Vitamin E to encourage new cell growth (400iu twice a day Ref: Clinical immunology of the Dog and Cat by Michael J Day) and also essential fatty acids.  It has been proven that essential fatty acids in therapeutic doses not only repair the skin barrier but they are also anti-inflammatory and have steroid sparing effects.

https://www.petmd.com/dog/care/fatty-acids-pet-skin-and-haircoat-health

You will have to watch that broken skin doesn't get infected, and if it does then you might need antibiotics or an antibacterial wash.

Happy birthday to your black lab for yesterday.  Essential fatty acid supplementation might help too.

Skin problems following long term treatment with preds are common and it can, and does, resolve when the preds are weaned off or at a low every other day dose but supplementation helps the function of the skin to return to normal.  It can get worse and sometimes ulcers develop, which are painful and stubborn to heal, and this is why giving supplements nourishes and helps the skin to recover.  It is not a quick fix though and  it will take several weeks before any improvement is seen, and within a few months things should be so much better if not resolved altogether.

Jo



This is an extract from another posting that may help:


Holland and Barratt, and other health food shops,  and Boots The Chemist  sell Natural Vitamin E, and you can buy Evening primrose oil and fish oil from the same, or from the supermarket.   Below are some links that might be useful to you but you can also check with your vet.
 
https://www.decodedscience.org/vitamin-e-another-tool-help-treat-canine-atopic-dermatitis/52103

https://thewholedog.com/omega3sdogs/

https://www.petcoach.co/article/omega-fatty-acids-sources-effects-and-therapeutic-uses-in-d/

https://www.carnivora.ca/html/Learning-Centre/EFA-Supplementation/index.cfm

https://www.petmd.com/blogs/nutritionnuggets/dr-coates/2014/august/using-omega-3-fatty-acids-effectively-and-safely-31972

Hi

It is good that Annie is on a gastroprotectant.

Langford is an excellent referral hospital and far be it from be to disagree but I have known dogs with SRMA (and IMPA) to show intermittent signs of lethargy and inappetence, and just not thriving, many months before the disease finally takes hold and a diagnosis is made, so I am not so sure that once this is fully under control Annie can't be a happy dog and maybe you will see a big difference in her demeanour.

Unfortunately the dose of preds was not correct so she has been temporarily disadvantaged but once you have go on top of this and the SRMA is in remission I hope you see a very different Annie.  SRMA ultimately carries a very good prognosis, so I am hopeful.

Jo

Hi Monica

I am so pleased Ripley is doing better. 

The dexamethasone test indicates the way you should go.    Usually, if the response is good then the glucocorticoid drug regimen is continued 48 hours after the injection of dex, by giving oral prednisolone at 1mg/kg/12hours.

Dexamethasone is a long acting injectable glucocorticoid that has a duration of 48-72 hours.    I don't really see the point in giving successive shots of dex when you are going to continue immunosuppressive treatment with prednisolone anyway.  I suppose it depends on the dose Ripley has received.  The idea is to see the response,  and if it is good then you switch to immunosuppressive doses of prednisolone tablets. 

If you look at the quote from Plumb's Veterinary Drug Handbook 8th Edition,  the maximum recommended dose of Cyclosporin for immunosuppression is: 

Immunosuppressive dose of Cyclosporin:  Empirical dosages generally range from 3-6mg/kg twice a day; or 5-7.5mg/kg/once  a day.   

The highest dose recommended is 6mg twice a day, so for dog weighing 17kg then the maximum recommended daily dose is 6mg twice a day equalling a daily dose of 204mg. 

Ripley already has some build up of Cyclosporin so I can't see why 200mg a day of Cyclosporin shouldn't be enough, but you have to take this up with the vet.    Doubling the current dose of Cyclosporin is a huge leap. 

Whether it be preds or any other medicine, more isn't necessarily better and often the side effects become a problem. The mainstay of treatment will be the immunosuppressive dose of preds and after two weeks it is hoped that the Cyclosporin will have good effect so the preds can be successfully lowered and take over the primary role of immunosuppression. 

You must see how Ripley is coping with this new drug regimen before you can decide how to lower the preds.  Ideally, following a drug regimen such as the one written by  Prof. Michael J Day  is best but you must see how Ripley is coping with the preds and go by her clinical signs.  If she is coping well then you may be able to follow the protocol but if she is not coping with the pred dose then you may have to lower it sooner.  It has to be assessed  on a daily  basis and adjust as necessary. 

Please make sure Ripley is on a gastroprotectant.

Good luck with this new regimen.

Jo

Puddles has been really doing well with all her numbers in line with heavy prednisone use since mid December.   Since being diagnosed she has been reduced from 50mg/day to now 20mg/day and is set to be reduced this week down to 15mg/day.  It will have been 30 days since her reduction from 25mg/day so she is due.   Her PCV has been a steady 41% since we bought her home with the exception of it dipping down to 38% once and then back up to 41%.  Muscles are coming back and she's more active, not much weight gain thanks to green beans.  Her problem now is I think she has calcinosis cutis on the back of her neck. The doctor thinks it's hot spots and treated her for such but I'm starting to disagree. I met with the Vet yesterday and found out our Chocolate Lab (birthday today, one year) is probably going to have allergies, lucky us.  I told her the skin around the 4 sores seemed to be harndened or thick which I'm assuming is why it's called calacinosis.  Other than reduction is there anything I can do for her.   She's doesn't seem to be uncomfortable and since she's a bulldog this is an area she can't chew.  Thank you!!!

Hi Jo
She has been on Famotodine after it had been decided that omeprazole for too long may have been causing the diarrhoea. The famotodine prescribed finished a couple of days ago and I checked and the vet's notes said finish the course. We see him again on Friday and will ask.
Another worry of ours has been that Annie has never been a 'normal ' bouncy puppy even before SRMA was diagnosed at 8 months. The vet at Langford said that SRMA would not have been behind this early lethargy. In the park other people always thought she was an old lady from her plodding walk. She also has never had a good appetite, needing to be tempted to eat. Having eaten a food for a week or two she would then refuse it.
Sorry to be so negative but I do wonder where we are going to end up.

Hello Jo

Ripley got a bit worse on Friday so we went to a vet who gave her a shot of Dexamethasone, she improved, she is not completely well, but definitely better (she can stand and walk).

We have also got the results of the cyclosporine dosage, and it's below the effective range, so she still hasn't been receiving an immunosuppressive treatment at all.

The new vet suggested to have three shots of Dexamethasone (so three days) and then switch to Prednisone for a while and introducing the Cyclosporine at the highest dosage, so we can take her off the Prednisone when the time comes.
I am wondering now, if the cyclosporine takes at least 15 days to kick in, shall we give Ripley 2 weeks of 35 mg Prednisone and 300mg Cyclosporine?
And then, how should we taper the Pred? I was thinking that since she is on Cyclosporine, we might be going a little bit faster than the standard protocol, as Cyclosporine should work on keeping her immune system at bay.

What do you think?
Thanks for all your precious suggestion, you are really helping me and Ripley

Monica