CIMDA

Thank you Jo, for your response.  I am in agreement with you that Oshie has not been on an appropriate dose of prednisone.  We saw the neuro vet today and even though a spinal tap and MRI are not diagnostic of these diseases, I think he is mad that I did not spend the $5000 to do them.  I am a physician and knew the treatment would be antibiotics and/or high dose steroids and the Internal Med vet was willing to treat him empirically.  Today, the neuro vet was taken aback when I said I didn't feel Oshie was given the full immunosuppressive dose of prednisone.  He does not want to increase the prednisone unless we do an infectious disease panel ($500) to rule out cryptococcus, toxo, etc, which I think is BS.  He did give me a script for cyclosporin 50 mg daily to add to the prednisone.

I am wondering if it is worth trying to increase the dose of prednisone to 5 mg twice a day and see how he does, or just leave it at 5 mg daily and add the cyclosporin.  Also if you would add the cyclosporin, would you do 25 mg twice a day, or do you think the 50 mg daily is ok?  Oshie weighed 10 lbs at the start, now at 13 lbs from the steroids.

Also, what gastroprotectant and dosage would you recommend?  we have many OTC meds to choose from.
Prevacid 24HR (lansoprazole)
Nexium 24HR (esomeprazole)
Prilosec OTC (omeprazole magnesium)
Zegerid OTC (omeprazole and sodium bicarbonate)
Tagamet HB (cimetidine)
Pepcid Complete or Pepcid AC (famotidine)
Axid AR (nizatidine)

Thanks for your input.  I really appreciate it.

That is brilliant news.   Thank you for the update on Freddie and for posting such encouraging news.  It certainly helps others in a similar situation.

Jo

Hi and welcome

I am so sorry that Oshie is having these problems.  It does seem that because there was a good improvement after starting the steroids that a presumptive diagnosis of an inflammatory AI disease is very likely to be accurate.

I don't know how much Oshie weighs but treatment for SRMA, or a similar inflammatory AI disease, is an immunosuppressive protocol of prednisolone which is 1mg/kg/12hours.  This dose is usually reduced by 25% after 3-4 weeks.  The best protocol that I have come across is by Prof M J Day.  See below:

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.



Any protocol has to be tailored to the individual dog because all dogs can react differently to steroids.  Also, large dogs do not cope so well with the side effects and small dogs, or puppies, often need higher dose because their metabolism is quicker than larger dogs.

I am assuming that 5mg of prednisolone is not an immunosuppressive dose for Oshie, so this is probably why you saw good improvement, because it acted as an anti-inflammatory, but because the dose was not high enough his immune system was not suppressed sufficiently (the immune system should be so suppressed that it is almost non existent) and therefore there were still circulating immune cells that were still programmed to  attack his body. This sort of inflammatory AI disease is very often progressive, so waiting 2 months before steroid therapy started will not have affected the final outcome, but not being on a high enough dose will mean that he would not have achieved remission and this is why he still has symptoms.

As Oshie has been on prednisolone for some months its effect will have built up in his body and this will cause side effects such as drug induced Cushing's syndrome.  From what you have written it seems that Oshie's immune system needs to be fully suppressed, but given the length of time that he has been on prednsiolone it is probably a better option to introduce another immunosuppressant, and there are several options.  The one that I favour at this time is Mycophenolate Mofetil (MMF).  This, or a different immunosuppressant drug, can be used alongside prednsiolone and if the side effects of prednsiolone become too much the dose can be weaned down and ultimately withdrawn. Your vet will have to assess if Oshie can tolerate a full immunosuppressive dose of prednsiolone.  As Oshie is a small boy some drugs may not be suitable because the tablet may not be able to be split to treat such a small boy.

IMPORTANT NOTE: PREDNISOLONE MUST NOT BE STOPPED ABRUPTLY.  IT MUST ALWAYS BE WEANED DOWN TO AN EVERY OTHER DAY DOSE BEFORE BEING WITHDRAWN. 

For other immunosuppressive drugs see this link:

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

The good news is, inflammatory AI diseases such as SRMA or IMPA respond really well to prednsiolone, and other immunosuppressive drugs and they are not generally life threatening, but the correct drugs, dosage and duration of treatment is crucial to reaching long term remission.   I have known countless dogs with SRMA and IMPA to reach long term remission with correct treatment and go on to live a happy pain free long life.  So don't think that Oshie will be any different. He can do it with the correct treatment.

Good luck

Jo
 

 

So happy I found this group so I can share my long story (sorry about that) and get some feedback. My little man, Oshie, was a very happy go lucky guy with always a smile in his face and a skip in his step! Oshie is a 10 lb maltipoo about 3 1/2 yrs old. Then, around Christmas, I started to notice his frown. He seemed sooooo unhappy. His tail was down and he would occasionally yelp when he was pet near his neck. Then he started occ shaking. I took him to the vet. He had a temp 103+ but all his labwork was normal. They gave him fluids under the skin. Several days later, he was not better so I took him back to the vet. Temp was higher >104. They gave him more fluids under the skin, a shot of rimadyl and some rimadyl tablets. He was better for a few days, then back to not being well at all. Again, another trip to the vet. I suggested maybe Lyme's, so they tested - neg. At this point I said we need to throw SOMETHING at this dog. They admitted they had no idea what was wrong and said they would give me a referral to Internal Medicine specialist.
They gave me an rx for doxycycline. He was on that for 8 days with little to no improvement. All this was over a period of about 2 months. On Feb 9th Oshie was so very sick so I took him to the Emergency Vet in our area. They kept him overnight to be transferred to Internal Medicine service the next day. Internal med vet repeated labs which did not show elevated WBC's, but very low platelets (which she attributed to his doxy treatment) She got a neuro consult which recommended spinal tap and MRI. They said they thought he had either bacterial meningitis or SRMA. I declined the tap and MRI and asked that we just go ahead and treat to see what happened. They gave me antibiotics the first day, but the next day called and started him on prednisone 5 mg daily. After starting the prednisone, Oshie really perked up. He was not 100% because he was still scraping his back toenails when he walked, but def better. He has been on 5 mg prednisone since 2/9 but in the past 2 weeks I have noticed a decline. Toenails scraping more, butt drifts to the right when he walks, head tilt to the right, occ yelp when touched near neck, seems to be confused and back legs don't have good coordination. He started shaking again one night and I gave him an extra dose of the prednisone which def gave him some relief. I already had made an appointment with Neuro for follow up, but called to tell them he seemed to be declining badly. They gave an rx for gabapentin and moved up the neuro appointment for tomorrow. He currently seems a little improved on the gabapentin.
Other info: he has gained 5 lbs since starting the steroids even though I am very careful not to overfeed him. And he has bilat luxating patellas which I'm sure are worse with the extra weight as he bunny hops and only squats to pee now.
So I have a few questions to pose.

He did not start on steroids until he had symptoms for 2 months. Is that too long for good outcome?

Was 5 mg too small a dose? Should it be increased or another agent added?

I quite honestly don't know if he will ever be completely normal. He is very miserable right now and I'm not sure I should continue to let him suffer. It absolutely breaks my heart every time he is rigid and posturing and crying out when touched. Did you think about putting your dog to sleep? Did you just push through the anguish and now have your normal dog back?

Thanks in advance for any wisdom, insight, info you can impart.

 I have come back to look at this site as there seems to be quite a few dogs with autoimmune diseases at the minute who owners are looking for help .... Just to answer the question posted above as I have only just seen it and it might help others ..... Freddie started on the steroids in the September and the reduction in steroids was followed slowly as shown on this site. He took his last tablet the following May and never needed to take any more for the IMPA. He pretty much was as he was before the steroids  and the IMPA
.

Thank you. X

           

This is great news Erica. 

I am so pleased that Elsie is doing well.  When you get to a very low dose of pred there are several ways that you can reduce and I do think that taking it slower, although it is not suppressing the immune system, helps to maintain homoeostasis and it is less of a shock to the system.

Personally, dropping to a low daily dose, as you did last time, and then going every other day for a couple of weeks, and then every third day for another couple of weeks, before leaving it off altogether is a nice gentle easing off of steroids, and it does no harm too.  You can go as slow as you feel is right.

Well done.  Let us know how it goes.

Jo

Elsie update.
She is now on 5mg per day. She is extremely well with plenty of energy, eating well and happy.
When we get to the stage of reducing from 5mg, is it better to give 5mg every other day or 2.5mg per day. (Last time the vet gave me 1mg tablets and we went from 5mg to 3mg per day).