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 1 
 on: Yesterday at 08:41:53 PM 
Started by Rachel Penfold - Last post by Rachel Penfold
Hi, thank you for responding I appreciate the info which I'm going to discuss with my vet. I'm not sure we are on the right track at the moment with his treatment as we don't seem to be making a lot of progress. I'm aware that these things can take a long time but there really hasn't been any improvement since we started & we are beginning to question whether it's fair on him to continue as we are.
Thank you again.

 2 
 on: December 11, 2017, 08:33:14 PM 
Started by Rachel Penfold - Last post by Jo CIMDA
Hi

I am not sure how much a Mexican Hairless dog weighs, not much more than about 20kg I suspect.  If this is so, 70mg of pred a day is too much for a dog of that size.  The starting immunosuppressive dose of prednisolone should be 1mg/kg/12 hours, any less and it won't be immunosuppressive and anymore and you run the risk of intolerable side effects.  So I am not surprised that he has drug induced Cushing's.

Polyarthritis responds very well to immunosuppressive doses of prednisolone and it is probably the best and most effective drug to use to treat this AI disease however, if the dose is too high to start with there will be a greater build up of corticosteroid in the body and that will produce bad, sometimes dangerous, side effects; you then have no choice but to lower the preds and it will probably be too soon which then leads to a relapse. 

I don't think the IMPA immune response has been triggered again, it is more likely that the disease has not been brought under control because the drug protocol was wrong and as you lowered the preds the immune cells, targeting the synovial fluid in the joints, has become active again.   If prednisolone is too high to  start with it causes unacceptable side effects and you have no choice but to prematurely reduce the pred dose.  The correct drug protocol is crucial to the outcome of the disease, and in achieving remission.   I doubt the Atopica is having much effect.  Although it is an immunosuppressive drug unfortunately, it doesn't always suit every dog or have the desired effect.

The fact that you have seen an  improvement since raising the preds indicates the way to go.  The problem you have now is how serious is his Cushing's symptoms?  Does he have high platelets, in which case you can give an antithrombotic dose of Aspirin to thin the blood.  How high are his liver enzymes?  Perhaps you an give him Milk thistle and SAMe to support his liver. 

If it isn't possible to put him back on an immunosuppressive dose of pred, or near immunosuppressive dose, then the other drug often used for IMPA is Leflunomide. 

Yes, leaky gut can trigger an inappropriate immune response but personally I doubt the food that has been recommended will be as good (or any better) than the diet you already give to him and I am not sure how relevant it is in this case.   I have heard good things about kefir but watch the fat content - even with his raw diet because when a dog is on pred, and some other drugs, it is always best to feed a low fat diet to avoid pancreatitis.   Dogs with an AI disease should be kept as natural as possible and that means limiting chemicals that are sometimes found in branded foods.
I have copied some info below that might be useful.
Jo

 Extract: WHAT TO EXPECT ONCE 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 anytime 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 up to half. 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.

"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.

How Do I Know if My Dog Will Relapse?

Until you have attempted to wean your dog off of the tablets for the first time you will not know if he is likely to relapse or not.  Sometimes during the weaning off process, before you even get down to an every other day dose, he may relapse.  If this happens then the drug dosage has to be raised, probably up to the last dose before the relapse (maybe a little higher, depending on the severity of the relapse) and then start the weaning process again.  If this happens again, then you and your vet may have to settle for keeping him on a low maintenance dose to achieve a good quality of life. A low, every other day maintenance dose of prednisolone is preferred to enable the dog’s liver to rest in between doses. There are many autoimmune diseases that carry a good, drug free prognosis.  The more common, serious autoimmune diseases that may not need long term steroid therapy are: primary immune-mediated polyarthritis, autoimmune haemolytic anaemia and thrombocytopenia. However, as previously stated, all dogs are different and it very much depends on the individual dog, the severity of the disease, the experience of the vet and the vigilance and compliance of its owner.
If a relapse occurs whilst the dog is still being treated then true remission has not been achieved.  If the dog has achieved remission and has enjoyed a period without drugs or is on EOD maintenance drugs, when a relapse occurs or he develops another autoimmune disease, he has encountered a ‘trigger factor’ which has induced this change.




 3 
 on: December 10, 2017, 07:10:06 PM 
Started by Rachel Penfold - Last post by Rachel Penfold
Evening, sorry if not posting in the correct bit still not entirely sure how a forum works!
I've had some really helpful info & advice previously regarding our Mexican hairless & his AI disease. Don't think vet is still quite sure what type of AI he has, poss polyarthritis think vasculitis has been ruled out tho now. He also now has drug induced Cushing. He started on 70mg pred p/day in sept & in the last few wks we have been slowly reducing the dose (he's also still on 200mg atopica daily) we dropped to 7.5mg last w/end but he went downhill again was very lame & depressed so it's gone back up to 15mg p/day & he's improved slightly. Vet is thinking there may poss be a digestive trigger such as leaky gut.. She has said she's had some success with AI cases when trying a hypoallergenic diet (hills z/d) & has suggested we give this ago before adding in another immunosuppressant. I raw feed & am really not keen on trying this but obviously if it helps then I'll give it a go. Have just ordered some kefir to start him on does anyone have any advice re diet helping with AI please.
Many thanks in advance

 4 
 on: December 10, 2017, 11:58:51 AM 
Started by Meeko - Last post by Jo CIMDA
Hi and welcome

I am sorry Meeko has myositis.  You have done the right thing by taking him to see a specialist and now Meeko is being treated with immunosuppressive drugs and you are seeing an improvement, he is hopefully on they way to remission. 

Myositis is a very painful and debilitating condition but as soon as the immune system is brought under control and the damage halted you can see  obvious signs of improvement and much less pain.   If he is having problems eating then you may have to raise his bowl and monitor him whilst he eats and drinks, making sure the food has a smooth transition down his oesophagus to avoid choking.

Is Meeko having a gastroprotectant?  If he isn't then perhaps you should ask the specialist to prescribe something like omeprazole or ranitidine to avoid any stomach ulcerations that may be caused by the drugs.

I have had a dog with myositis and he reached remission with the correct medication.  The hard part, such as obtaining a diagnosis and starting treatment,  is over for Meeko, so with the watchful eye of your specialist I hope you will see much improvement and he will get back to being a happy dog again.

Jo


 5 
 on: December 09, 2017, 04:47:21 PM 
Started by Meeko - Last post by Meeko
Meeko is One of my family’s dearly loved dachshunds. He illness began in September when he was occasionally refusing to eat. After numerous trips to the vet, He has very recently been diagnosed with Myositis which has rapidly affected all his muscles. Our family veterinary hospital referred him to an emergency care veterinary center just before Thanksgiving due to heart arrhythmia/ myocarditis, followed by breathing issues due to pulmonary edema. He spent two weekends with urgent care, he is now under the care of a certified cardiologist who is working with an internal medicine specialist to try to treat him. He is home today on a lot of meds, his heart and lungs are greatly improved, he is on pregnazone, cyclosporine, antibiotics etc.  We are waiting for tests results, to rule out parasites but our Dr. feels this is autoimmune and is treating him for this. Poor little guy went from 19 lbs to 14 lbs in two months time. He is very weak. It has been challenging getting him to eat and take his meds. It is very heartbreaking to watch him go through this. Found this site looking for support and advice. Thank You 🙏

 6 
 on: December 08, 2017, 03:37:37 PM 
Started by KatColM_O - Last post by Jo CIMDA
Hi

Omeprazole might be  a better gastroprotectant and it will heal an ulcer. You are very lucky to have a radiologist in the family.

Cyclosporin can sometimes upset the tummy at first and if this happens  lower the dose for a few days to customise her to the new drug.

Good luck
Jo

 7 
 on: December 08, 2017, 03:28:10 PM 
Started by KlassyBandit - Last post by Jo CIMDA
Hi and welcome

I am sorry Rosie has been so unwell. It seems Michigan State Uni have done a good job in getting her through this.

I have known other dogs to have immune mediated neutropenia alongside haemolytic anaemia and thrombocytopenia (or Evan's syndrome), but to have all three haematological autoimmune diseases at the same time is rare.    IM neutropenia is more rare than the other two blood AI diseases.

The treatment should be the same as if Rosie had just one AI disease, and that is with immunosuppressive drugs, such as prednisolone but the fact that she has more than one haematological AI disease is an added concern.  As she has responded  well to prednisolone, and this is great news, and in future, should she ever relapse, you know exactly how to treat her. 

The best way to avoid a relapse is to limit any potential triggers such as vaccination, regular spot-on treatment, worming etc and of course try to feed her naturally etc.

Jo





 8 
 on: December 08, 2017, 03:11:36 PM 
Started by Hobart999 - Last post by Jo CIMDA
Hi

I'm sorry Nika is not doing well on the drugs.  It seems you are damned if you do and damned if you don't!

Clearly though the steroids have some good effect on reducing the inflammation, so, not withstanding what you specialist said,  why not try Tacrolimus (Protopic)?  It is known to have good effect on localised inflammation without causing systemic problems, and what have you got to lose?  Also, I would start Nika on therapeutic doses of evening primrose oil and fish oil and natural Vitamin E.  Essential fatty acids in therapeutic doses are known as 'steroid sparing' and this has been proven, so why not start Nika on EFA's - but it has to be in therapeutic doses otherwise it will not be sufficient to have good effect.

Is Nika on a liver support such as Milk Thistle and SAMe?  If she isn't then you should start this straight away.  It will help her liver cope with the onslaught of any drugs given.

Another option, which would have to be discussed with your vet,  might be to give a lower dose of Cyclosporin with powered grapefruit or ketoconazole.  Grapefruit and Ketoconazole enhance the effect of Cyclosporin and this may allow a lower dose to be given and thereby limiting the harmful effect on Nika's liver.   

I hope you can sort this out very soon.  It is very frustrating when a problem is localised can't be brought under control.

Jo





 9 
 on: December 08, 2017, 06:45:44 AM 
Started by KlassyBandit - Last post by KlassyBandit
Hi everyone,
This past August my Shiba Inue, Rosie, became very ill very quickly.  My primary vet ran a cbc on her and once results were back referred us to a specialty clinic.  She had a temperature of 105.8 and very abnormal blood work.

August 9, 2017 -  CBC: WBC 2.3, RBC 7.0, HGB 13.6, HCT 40%, MCV 56, MCH 19.4, MCHC 35, Neut 0, Lymph 1,886, Mono 414, Eos 0, Baso 0 - noted inappropriate metarubricytes Chem: TP 6.6, Alb 2.9, Glob 3.7, A/G Ratio 0.8, ALT 22, ALP 178, BUN 9, Creat 1.1, BUN/Creat Ratio 8, Glucose 93

August 10, 2017 - CBC: WBC 2.1, RBC, 5.62, HGB 10.8, HCT 29.2, MCV 52, MCH 19.2, MCHC 37.0, Neut 2.0, Lymph 58.0, Mono 34.0, Platelets 28

A Coombs test was performed and it was positive 1:128 suspecting immune mediated disease

Basically, all blood lines were critically low.  Her platelets and rbc did respond to steroid based treatment,but for 5 weeks her wbc and neutrofils remained very low.  MSU performed a bone marrow biopsy and it was determined that her neutrofils were not maturing - the cells looked healthy but not maturing and not many cells.

The doctors at Michigan State Univ told me that they have not seem blood act as Rosie's is and I have been researching and talking to other dog owners who have pets that suffer from autoimmune diseases and I have yet to find another case similar to Rosie's.

Does anyone here have any insight or know of similar cases?

As of right now Rosie is doing well.  We almost lost her twice in August but then she did start to respond to being on Prednisone alone (severe reaction to Atopica) but I worry so much especially since I don't know of anyone else who has a similar experience.

 10 
 on: December 08, 2017, 04:21:12 AM 
Started by KatColM_O - Last post by KatColM_O
Hi Jo, Thank you for the information. I will discuss the prednisone dosing schedule below. She had been given 20mg 2x/day - she hovers between 45-50lbs so that's right on for the lowest dosing of 1mg/kg every 12 hrs. She threw up in the middle of the night of day 2 on the med (normal looking throw up for her), but another day after and she was vomiting was looked at first like diarrhea (I came home to a messy house and didn't know what had happened...then I read about vomit from ulcers looking like coffee grounds and it made sense).

She had blood work done again today and started her first dose of the cyclosporine this evening. We have a follow-up for blood work scheduled for Monday. I got copies of all of her records while I was at the vets office today so I am going to review and can post more specifics on the different blood counts.

I haven't considered Addison's disease, but will read up on it and see if anything stands out in the records I have. The vet tech also sent me a link to the ultrasounds and other diagnostic imaging that has been done in the last year. I am not sure I'll be able to tell much from that, but I will be curious to take a look. My sister's fiance is a radiologist so I may ask for his expert opinion...even though I know humans and dogs are very different.

I was able to get Millie to eagerly eat her breakfast this morning by adding a bit of olive oil to it and she seemed to be in better spirits when I got home from work. I'll try to continue to encourage eating and hopefully we will get some answers soon.

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