SMRA relapse

[RSB]

Hello everyone. Came across this great forum whilst researching srma. We adopted a 1 year old dog in March, and in July he had his first episode of SMRA (we have not had this diagnosed with a spinal tap or MRI, but purely based on his symptons and response to prednisolone). He was on the steroids for 5-6 weeks and though September and October was back to his old happy self, and finally gained back his lost weight and muscle mass. (He lost muscle mass a lot in his head and looked very sunken). Last week he had a relapse - we caught this early after noticing a fever. He didn't start with neck stiffness/pain until 3 days later when he was already in the vets on IV fluids, antibitocs and then they started the steroids again. He is drinking and weeing sooooo much we are having to leave the door open on a night so he can come and go as he pleases.
I have a few questions for you all if I may please:
Do you think 5 weeks of the prednisolone is enough to take him into full remission without another relapse?
What have you done to help strengthen your dogs immune system whilst on this treatment? (Ours got conjunctivitus last time, and I am concious they can get infections easily.)
How many if any relapses have you experienced? (I am so worried about him going through this again)
Are there any supplements we can give him to help him naturally?

We are feeding him more of his dry food and also giving salmon, tuna, chicken, eggs, vegetables in between meals to bulk him back up.

Thanks all for your support.

[Jo CIMDA]

Hi and welcome

I am sorry your dog has relapsed.

To answer your questions:

5 weeks is certainly not long enough to bring a dog into long term remission.  Please take a look at the protocol below.  This is the best protocol I have come across and Prof Day is among the top immunologists in the world so the protocol can be confidently used as a guide.

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.

Extract from my seminar notes:

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.

Your vet may want to introduce another drug called Azathioprine, to use in combination with prednisolone.  This will allow the prednisolone to be weaned down, which reduces the side effects, and still maintain a good level of immunosuppression.

The dose of azathioprine 2mg/kg/24 or 48 hrs, can be reduced initially by giving a lower dose tablet per day, or gradually reducing from daily dosing to every 2nd day, every 3rd day, every 4th day etc.....  Remember, azathioprine tablets should not be broken or handled without gloves.

When a dog has an AI disease the treatment is to significantly lower the immune response so the destruction of the 'good' cells stops, so you shouldn't use anything to enhance the immune system.  All  you can do if the dog gets an infection is to treat with antibiotics.  Also, it is a good idea not to take your dog to a popular dog walking areas just in case he picks up an infection.  Sometimes a vet will give immunosuppressive doses of prednisolone and at the same time prescribe antibiotics, just in case the dog gets an infection. 

In order to bring an AI disease under control the immune system has to be virtually wiped out by the drugs.  This allows the body to get back to working normally again and by the time you slowly reduce the steroids the immune system should not longer be confused (well this is the aim). For a dog to relapse it has either met another 'trigger' or the drug regimen, dose and/or duration, wasn't adequate.

Relapses are not uncommon and the best way to try to avoid this is to have the correct drug protocol and wean off slowly - checking all the time for unacceptable side effects.

Once a dog is in remission, it is hoped that the dog will stay in remission but there are no guarantees.  For a dog to get an AI disease it has to have a genetic predisposition and then it has to meet a 'trigger' that will cause the immune system to become confused and start to attack healthy cells.  You can't change the genetic predisposition but you can limit the trigger factors such as chemicals, drugs, vaccines etc., and hopefully long term remission will be achieved.

His diet sounds very good but make sure it is low in fat and it is better to feed little and often to avoid pancreatitis, which can occur when a dog is on prednisolone.  It is also prudent to give the dog a gastroprotectant such as Omeprazole or Ranitidine to avoid stomach upset or ulcers developing.

You can give supplements such as Milk Thistle and SAMe to help the liver if you want because the liver has to work hard to process the steroids. 

Your dog responded well to steroids the last time so he should respond well this time, so fingers crossed - and make sure the drug regimen is correct.

Jo

[RSB]

Thanks so much Jo, a very interesting read and much appreciated. We are in Australia (but I am from the UK) and it is hotting up now and so our dog is really feeling the heat and the panting from the steroids is now in overdrive. He has sparks of energy first thing in the morning and late on an evening when it is cooler, but it worries me to see him so lethargic and walking around to find a cool spot during the day. He is a cattle dog cross so is usually very difficult to tire out!
I am giving him yakult each morning for his stomach and I did wonder why this time our vet didnt give him a gastro protectant (they did on his first bout) so I will check about that.

Thanks again

[Browndeb]

Sorry If this question has been asked before but is it usual for a dog with AIHA to suffer with UTI's.  My Irish Setter Chico was diagnosed in August and this is the 3rd time he has been given antibiotics fir a UTI although the vet did tel me that AIHA can affect the liver and kidneys. He is on 50mg of Azathioprine, 50 mg of Pred, 1/4 of a 75mg aspirin.  I also give him Zantac 75 mg ( twice a day); milk thistle, tree barks powder.  My new vet is into holistic medicine to and has prescribed him a tonic

[Jo CIMDA]

Hi

In answer to your question, a dog on immunosuppressive therapy is prone to UTI's and it is pretty common.  This is because the immune system is suppressed and allows infections to develop.  As the immunosuppressive drugs are lowered this should not be such a problem and any effect on the liver will subside. Kidney issues are not usually a problem.

UTI's can be very persistent and it might need a much longer course of antibiotics to get rid of the bacteria.  Antibiotics for 3 - 4 weeks or even longer  is not unusual and also if the first antibiotic doesn't work then your vet might have to try a different one.

I am concerned that Chico was diagnosed in August and he is still on 50mg pred a day.  I would have hoped this would be lower 3 months after diagnosis.

Please take a look at the Michael J Day immunosuppressive drug protocol 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.


"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.

Keeping a dog on prednisolone any longer than necessary will not be doing any good and it can cause intolerable side effects. 

As long as the AIHA is under control then you should start to lower the preds.  Aza can be lowered at a later date.

Unfortunately holistic medicine can't bring autoimmune disease under control it can optimise Chico's good health, so that is a good idea.

Jo

[Jo CIMDA]

Hi

The heat can be a problem when they are on high doses of steroids.

In the UK you can buy Ranitidine from the supermarket.  Dose: Ranitidine:  2mg/kg/three times a day. (Canine Medicine and Therapeutics by Neil Gorman)

Jo