CIMDA

Hi and welcome

I am sorry that your Boxer has SLO.  It is a very painful disease but the good news is, it is not life threatening  and it does not have to be treated with immunosuppressive doses of steroids.

If you would like to email me at    cimda@aslog.co.uk     I can send you my SLO seminar notes, which should provide all the information that you need.

Jo
 

Hi

A PCV of 42 is good news and I hope the vet will start to reduce the preds very soon.

Dog that have not been on a gastroprotectant and have been on high doses of steroids for a while can develop gastric ulcers. 

Jo


Here is some information about what to expect when your dog is on immunosuppressive therapy with prednsiolone.

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. 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.

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. 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.

Hi

I am sorry that Sheltie has paralysis.  How is this being treated?

https://www.theanic.com/wp-content/uploads/2019/04/polyradiculoneuritis.pdf

Polyradiculoneuritis in the dog is not a common diagnosis and I understand that there is no specific test that will give a definitive diagnosis. 

The more commonly diagnosed  AI diseases that cause muscle weakness are, Myasthenia Gravis (MG) and  polymyositis. 

As there are no definitive tests for polyradiculoneuritis, and as it is an autoimmune disease that affects the nerves, causing weakness and paralysis, and is possibly similar to myasthenia gravis, I wonder if the vet is treating it with immunosuppressive drugs such as Leflunomide, Mycophenolate or Pyridostigmine Bromide? 

The usual and most go-to drug for treating AI disease is immunosuppressive doses of prednsiolone, but this is not recommended for treating diseases with muscle weakness because that is a side effect of the preds. Low doses of preds can be added to an immunosuppressive drug regimen but it is not used as the primary drug.

With an AI disease such as MG and polymyositis,  the primary cause has to be treated with immunosuppressive therapy (significantly suppressing the immune system to stop the destruction) but often with this type of AI disease mobility does not always return to 100%, this is why it is best to use immunosuppressive therapy as soon as possible, to stop further destruction and attempting to retain as much mobility as possible.

Depending on the dog's mobility, perhaps hydrotherapy can be given, even a treadmill but that would have to be assessed on an individual basis.

I would ask the vet if there is a possibility of this not being polyradiculoneuritis and whether treatment with one of the above drugs could be considered.

I hope things improve

Jo

Hi Karen

Does Pippa still have petichiae?  Could it have been a one off occurrence?    It can't be thrombocytopenia because her platelets are certainly more than adequate.  I agree, I wouldn't be happy for her to stay on immunosuppressive doses of preds unless it was absolutely necessary.

I do hope you get some answers very soon.

Jo

Have you seen the information here?: http://cimda.co.uk/smf/index.php?topic=22.0 Also if you use the search facility on the main page there are plenty of posts with regard to SLO that you may find helpful before your vet visit.

Hi there

As of a blood test last week Fergus PCV was 42 so vets were very pleased. We have another blood test tomorrow and if results have remained stable then a blood smear will be done, and pending those results we may be able to reduce steroids.

I have spoken to specialist twice about the tummy protectant, she was of the view that there was no medical evidence to support giving this to Fergus, and as Fergus has a sensitive tummy and has been prone to bouts of colitis she was loathe to prescribe one. Should I raise this again?

Am noticing loss of weight, possibly muscle tone and fur, drinking is increased (though we were told increased thirst/hunger is a side effect of the steroids), is there anything else we can do to help support our boy?

Hi all hope I'm doing this right. Great to find this page. My boxer dog is seeing a dermatologist next Wednesday. I work at a vets and its likely she has SLO has she has all the symptoms so they've referred me on. She's lost about 11 nails in last 3 weeks. Ive added some fish oil to her food & waiting to see what they say. Very upsetting and worrying of course 😞

I have no experience of this but there is a thread on this site that mentions it and in which Jo has posted some links that may be helpful:

The thread here: http://cimda.co.uk/smf/index.php?topic=898.msg8394#msg8394

and the two posts I have copied here:



A mixed update on Saba.

The good news is that she is regaining strength and has even managed to walk a few steps unaided today. It's wobbly and it's short lived but it is a long way from where she was a week ago. Her liver enzymes had halved last week from the very high levels and have almost halved again in today's blood results. She continues to eat, catch flies and loves her morning visit to the park to see her buddies.

The bad news is that we decided to measure the muscle enzyme last week as there is concern at the amount of muscle wastage we have seen with her. It was above 1700 whereas I gather the normal is 400. This week it is back to 1100. On this basis the specialist believes there is a muscle myopathy going on and has suggested we should be increasing the pred again. I'm reluctant to given the trend is improving, albeit not as strongly as we might like and pred is not going to help us in the fight against the polyradiculoneuritis. We have agreed to give it another week with just the 5mg pred daily plus the leflunomide.

I have two questions. Is there any reason other than yet another immune disease involving muscle myopathy that the CK result would be running high? The vet did mention the fact that she is basically full time recumbent might boost it a little but she didn't think as much as this.  The second question is, if we do face a muscle myopathy, are we just fighting a losing battle with IMPA, polyradiculoneuritis and muscle myopathy? Is it just too much to expect her to fight on three fronts?


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Re: Saba - 10 year old vizsla with IMPA

« Reply #44 on: January 27, 2017, 09:16:12 AM »

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Hi Rebecca

I am not a vet but my take on Saba's elevated CK and her muscle atrophy is this.

Since drastically reducing the preds you have seen an improvement in her strength, and her liver enzymes and CK enzymes have reduced.  One of the main causes of all three of these symptoms is overuse of corticosteroids (prednisolone). 

There is no doubt that Saba's prednisolone reduction regime was incredibly slow and even if she does have an additional muscle disease, polyradiculoneuritis, her drug history alone would suggest that these symptoms could reasonably be due to the high and prolonged doses of steroids. 

If you see the links below one of the causes of high CK is hyperadrenocorticism, which is Cushing's disease.  The fact that the CK and liver enzymes have reduced, in my opinion,  can only be due to the much reduced dose of prednisolone.

I think you have a lot to be happy about right now and if her body is given the chance to repair itself from the insult of the preds then I think (I hope ) you will see a much improved Saba soon.

 I don't think you are losing this battle, I think you are just starting to win it.

Good luck

Jo


http://www.the-vet.net/DVMWiz/Vetlibrary/Lab-%20creatine_kinase.htm

http://researchonline.jcu.edu.au/9250/1/13_clinical_udpate_Drug_induced_muscle_disorders_published.pdf

Has anyone had experience of this issue which results in paralysis and if so what are the recommendations for rehab?

My agility trainer has a 10yr old Sheltie that has this currently

Regards

Sue

Hi Jo
Just had call from vet. Platelets all normal (217 in house, 138 in lab but lots of clumping so would be in normal range). So Pippa has unexplained petichiae. Got to keep her on steroids?, keep her safe and take her back on Thursday (earliest appointment!). The vet didn’t have any idea what it could be! So I have sent an email to the specialist who treated her for Aspergillosis and asked them some questions. Don’t like the ideA of her being on ‘precautionary steroids’ when they don’t know what is wrong.