CIMDA

Hi

Yes, I think Poppy will benefit from hydrotherapy.  It will take many months for the muscles to return to full strength, but it will come.  It is a slow process.  The good news is she is in remission.

Jo

 Hi everyone, My greyhound Poppy has been ill with AI for almost 17months now  ,she presented with all the symptoms of SRMA at first, this was over the Christmas period so the labs were closed and my vet was limited to what tests he could do , luckily he thought it was an AI and the meninges were affected  she was given Loxicom to try to bring her temperature down ,antibiotics  and steroids ,she started to improve then suddenly  developed a stilted gait and was in a lot of pain . the symptoms of SRMA had gone but the vet was concerned as her inflammatory markers were high  and her white blood cell count was raised . He referred her to a veterinary specialist centre  where after multiple tests,scans and joint tapping she was diagnosed with IMPA . They recommended steroids as the main treatment  and my vet was seeing her on a regular basis to monitor her . she seemed to relapse when we got down to 15mg of prednisolone  with the return of the stilted gait , but what we have recently been told is that it was probably  an adverse effect of the steroids causing muscle weakness, after a long discussion with my vet it was decided 2 weeks ago to gradually reduce the steroids, she has had an xray of her legs and sp;ine  and nothing showed up she has been on a reduced dose of  one and a half prednisolone for 2 weeks and i am due to reduce it to one tablet a day for 2 weeks as from today. The problem she has now is that her back legs are still weak when she gets up from resting she either limps on one back leg or holds it up   but she is still keen to walk  so every hour i put her lead on and walk her around the garden a few times  and she is fine ,still a bit wobbly . My question is ,we are due to see the vet next Wednesday , do i carry on with what i am doing  or get an earlier appt . She is very well in all aspects apart from  her back legs ,she has a good appetite, is toileting normally and is bright and alert in herself. She has lost her muscle mass  and i'm thinking it  will take time to build this up slowly again . My vet does have a hydrotherapy treadmill  would she benefit from this So many questions, Sorry !!! Yvie

Hi Deborah and welcome to you and George.

I am sorry George is having these problems.  I will try to answer your questions in the hope it may clarify things for you.

This is an excellent website for all things veterinary, and it is very reliable.

http://veterinarymedicine.dvm360.com/recognizing-and-treating-immune-mediated-polyarthritis-dogs


 He goes hopping lame all of a sudden but never has a temperature.  Is it normal for IMPA to come on so suddenly and acutely and does it always present with a temperature?

IMPA is one of the autoimmune diseases that is often categorised as the primary cause of  'Fevers of unknown origin'.  So, yes, it is usual for a dog with IMPA to have a high fever, sometimes in excess of 106.  IMPA often starts with intermittent lameness but if it is not diagnosed and treated  it progresses to lameness on all four legs with multiple joint involvement.  If a diagnosis is made early in the disease process the lameness may only be in a two or three joints.  IMPA can occur in combination with other AI diseases and this may include inflammatory bowel disease.

-  Shouldn't the inflammation levels be the same in all joints (his is massive in one elbow and much lower levels in other joints)?

I think this has been answered above.

-  Limp has always come on very suddenly and always Spring/Summer or when the ground is very hard (he has had bouts of limping in previous years which has also followed this pattern).

Autoimmune disease has to be triggered by something and this may be of a seasonal nature.  Vaccination can trigger IMPA.

-  With his current right leg limp (and previous limps), if we rest him completely (no walk, on lead in garden, no jumping on furniture) we can get the limp to go, but as soon as he exercises again it comes back.  With IMPA is it normal for exercise to make it worse?

Yes exercise will make the pain much worse.  IMPA is a very painful AI disease and it is progressive, so it may wax and wane but it will get worse if it is not treated with immunosuppressive therapy.   


I've got a couple of questions re Pred:

-  George has been on Ranitidine twice a day for two years now, due to reflux, plant eating and vomiting bile.  The Ranitidine controls this, but it all comes back if stopped.  Should I keep him on Ranitidine or would Omeprazole work better for protecting his stomach whilst on Pred?

Ranitidine and Omeprazole are both used for prevention of gastric ulceration when high doses of preds are used.  Either can do the job but Omeprazole is , I think, more commonly used. 

-  He has an ongoing lip fold yeast infection which is controlled but won't go (gets ulcerated) - I imagine this will get worse.  The vet says use Hibiscrub which doesn't help much - is there anything you recommend?   

It is very likely to get worse if his immune system is significantly suppressed.  I think all you can do is to use the recommended yeast controlling preparations and antibiotics if there is infection present.



-  The vet has said two weeks on Pred, then more joint taps to check it is working.  Does this sound a good plan?  How can we tell that its working due to the immune system being suppressed rather than just because of the anti inflammatory effects of Pred?[/b][/i]

Personally, I see no point in doing joint taps when a dog is on high doses of pred.  The steroids will mask the results and  he will have to be put out under a general anaesthetic to prove nothing.  Resolution of the disease by following a recommended immunosuppressive drug protocol, such as the Michael J Day protocol is the usual way to bring IMPA into remission.

I suggest you have a chat with the internal medicine specialist again and voice your concerns and ask if the test proved positive  for IMPA. Steroids are wonderful anti-inflammatory drugs, so I would expect Geroge's limp to improve somewhat but if you don't have to use them then there are other treatments for joint problems.

Good luck

Jo

Hi,
I have a lovely 8 year old Airedale called George and am so worried as he will shortly be starting on high dose Pred due to a recent IMPA diagnosis.

George has had food responsive IBD for the last 3 years and sadly cannot eat anything at all other than his kibble which he does do very well on.   Last July 18 he got up from sleeping and could hardly weight bear on his right leg due to pain in a toe joint.  He improved with rest, but didn't resolve so we got referred to Davies Vet Specialists, who did scans (normal), joint taps (inconclusive as normal apart from right elbow had a few abnormal cells) and a steriod jab into the toe joint.  4 days later he was sound.

Then this year in Feb after some waxing and waning IBD symptoms, he had a really bad vomiting session with terrible tummy pain.  He recovered but a week later got up one evening and could hardly weight bear on his right leg again. I found his elbow painful with two fluid lumps on it.  Our vet found no temperature and gave him a Tramadol jab which knocked him out for 7 hours solid (barely even opened his eyes!).  The following day he was miraculously sound and the swelling went after a few days.  He went back to normal exercise but didn't seem 100% as he was not running around quite as much as normal.

In April he got up after resting and couldn't weight bear on right leg again.  He was so lame and in pain we had to put his harness on and help him out to toilet.  After a couple of days like this (Easter & vet closed) he was a lot better but still limping slightly.  No temperature. Our vet referred us back to Davies, who found the following:

Heart murmur - scan showed low grade due to leaking heart valves
Spleen looked generally swollen, also two masses on spleen & biopsies showed hyperplasia
Pancreas showed sign of previous pancreatitis.
CT scan of forelimbs was normal
Joint taps of right elbow showed high levels of inflammatory cells
Joint taps of left elbow and both wrists showed low levels of inflammatory cells
All joint fluid was a watery consistency
Fluid cultures negative for bacteria

The vet called me with the results and recommended he starts on Pred at 50 mg per day (he weighs 25kg) which I was totally horrified at, but after reading online and the advice on here I now understand and realise this dose is correct.  However, I've got a few niggling doubts that I'm not sure quite fit with IMPA and wondered what your thoughts were:

-  He goes hopping lame all of a sudden but never has a temperature.  Is it normal for IMPA to come on so suddenly and acutely and does it always present with a temperature?
-  Shouldn't the inflammation levels be the same in all joints (his is massive in one elbow and much lower levels in other joints)?
-  Limp has always come on very suddenly and always Spring/Summer or when the ground is very hard (he has had bouts of limping in previous years which has also followed this pattern).
-  With his current right leg limp (and previous limps), if we rest him completely (no walk, on lead in garden, no jumping on furniture) we can get the limp to go, but as soon as he exercises again it comes back.  With IMPA is it normal for exercise to make it worse?
-  He always has a good appetite.

I've got a couple of questions re Pred:

-  George has been on Ranitidine twice a day for two years now, due to reflux, plant eating and vomiting bile.  The Ranitidine controls this, but it all comes back if stopped.  Should I keep him on Ranitidine or would Omeprazole work better for protecting his stomach whilst on Pred?
-  He has an ongoing lip fold yeast infection which is controlled but won't go (gets ulcerated) - I imagine this will get worse.  The vet says use Hibiscrub which doesn't help much - is there anything you recommend?
-  The vet has said two weeks on Pred, then more joint taps to check it is working.  Does this sound a good plan?  How can we tell that its working due to the immune system being suppressed rather than just because of the anti inflammatory effects of Pred?

To say I'm nervous about the Pred is an understatement, I feel completely sick about it, I can't sleep, I can't concentrate at work.  I so want to help my lovely boy, but feel overwhelmed at the prospect of him being really sick on the Pred esp as he has always been so sensitive to oral drugs and his tummy, let alone all its normal side effects.  I feel his limping is different/worse than on previous occasions, as he is much more lethargic and quiet in himself with it this time which makes me sad.  Gosh wouldn't it be easier if they could talk!

Sorry for the long post and thanks a million for any help, advice or encouragement you can give.

Deborah (and George)

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).  Zantac (Ranitidine) may also be prescribed to take away the excess acid. 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 is 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.

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.

Hi and Welcome

I am sorry Rufus has IMPA.  The good news is IMPA responds very well to prednsiolone but it has to be in the correct dosage and follow a good immunosuppressive drug protocol.

I believe the average weight of a male Springer spaniel is 20-25kg.    The recommended starting immunosuppressive dose of prednsiolone is 1mg/kg/12 hours, so it is very likely that Rufus is on a higher than recommended dose.  There are articles that recommend prednisolone at 2mg/kg/twice a day and more, but 1mg/kg/12hours is immunosuppressive and any higher dose will not provide more immunosuppression but will produce more side effects.     See below,  the quote from Plumb's Veterinary Drug Handbook, 8th Edition.

The best drug protocol I have come across is by Prof. Michael J Day.  Prof Day is among the world's top immunologists and his protocol can be confidently used as a guide and adjusted to the individual.

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael Day BSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.

Prednisolone:  "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.


The muscle loss you are seeing is definitely due to the prednisolone and many of the other clinical signs he is bound to be showing.   I will post some information about what to expect when a dog is on immunosuppressive doses of prednsiolone.

If Rufus isn't on something to protect his stomach from the excess acid that the steroids produce, then he should be.   Omeprazole is often prescribed or Ranitidine can be bought from the chemist or supermarket.

You should return to your vet, or ask for a referral to see a specialist in internal medicine, and question why Rufus is on such a high dose of prednsiolone.  Prednisolone is an incredible drug and it works very well but the side effects mustn't be ignored.  It is a fine balance between control and resolution of the disease and management of the side effects of the drug.  A vet friend of mine always says "listen to what your eyes are telling you".  In other words, take notice of the clinical signs.  If, when the preds are lowered, signs of IMPA return then it would be prudent to introduce a different immunosuppressive drug as a combination therapy but the may not be necessary if a good protocol is followed.  Often with IMPA, a relapse may occur but that is when the preds are at a much lower dose.

I hope you can work with your vet.
Jo

Hi, I've got a 6 yr old Springer called Rufus. I was given the link to this forum from a lady on fb on a Springer group.
Two weeks ago my vet diagnosed Rufus with IMPA I hadn't heard of this illness or had any knowledge of it.
Rufus was a healthy, active, fit and happy Springer until one day he started limping on his left hind leg. This then moved to his front right . I took him to the vets that gave him antibiotics and anti inflammatory medication. A week later he was lame on the right hind, the vet did Xrays, blood tests and took joint fluid. The diagnosis was IMPA. Rufus has been on 60mg of Prednidale a day for the last 11 days , he went back to the vets on Tuesday 07/05 and he has given him another 2 weeks of the steroids.
Rufus has lost over 3kg in 2 weeks, he's lost so much muscle he's so thin , I'm heartbroken for him to have gone from a fit, healthy,  happy Springer to a sad, thin shadow of himself.
I'm hoping I may find some information and help on this forum.
Thankyou in advance. Lucie x

Hi and thank you.

I have no idea, as I just went by the internet,  but it is worth checking as you say.  Perhaps they have more than one surgery.

Many thanks for highlighting a potential problem.

Jo

Hi,
Have been following your thread with interest- such a worrying time for you. I take my dog with MUO to Wear referrals Michael Mol but it is in Bradbury, Stockton . The link Jo gave also seems to suggest Bradbury. It may be worth checking Wear referrals location before talking to your vet. Sorry if I have misunderstood and muddied the waters.

Thanks for your thorough reply. Our vet did raise the issue of bone marrow suppression this week. Like most general vets, she's not an expert in IMHA, but she does have experience treating it. We see the IM specialist next week, and I think we are on our way to a more aggressive taper with the mycophenolate to support her as we go. I'll ask about the EFAs and vitamin E. She has taken a daily dose of Wellactin in the past, but with all of the warnings about low fat diets, I stopped. Thanks again for your advice!