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Author Topic: Diet & AI  (Read 926 times)

Rachel Penfold

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Diet & AI
« on: December 10, 2017, 07:10:06 PM »

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
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Jo CIMDA

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Re: Diet & AI
« Reply #1 on: December 11, 2017, 08:33:14 PM »

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.



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Rachel Penfold

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Re: Diet & AI
« Reply #2 on: December 12, 2017, 08:41:53 PM »

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.
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Jo CIMDA

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Re: Diet & AI
« Reply #3 on: December 14, 2017, 09:17:16 AM »

HI

I am sorry to hear that you are not sure if it fair on him to continue with the present therapy but  I do understand, and all I can say is ALWAYS, the correct drug regimen is crucial to the outcome and if it is wrong then you will not achieve your goal.  Conversely, if the drug therapy is correct you have every chance, especially with an AI disease like IMPA, that you will have a successful outcome and remission achieved. Primary IMPA isn't considered a life threatening AI disease, and it can and does respond well to the correct immunosuppressive dose of  prednisolone.  Sometimes, especially with IMPA, it can take a couple of years of waxing and waning of symptoms to settle and then many dogs will go on to a normal life without further episodes.  So given that the drug protocol so far hasn't been perfect for treating IMPA, as long as the side effects of the drugs allow, you have nothing to lose by trying the drug protocol by Michael J Day.  He is a top immunologist who is highly respected by other world leaders in this field. 

The drug regimen is key to remission. 

Jo
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Rachel Penfold

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Re: Diet & AI
« Reply #4 on: December 28, 2017, 07:37:20 PM »

Hi, thank you for ur reply again! It's much appreciated it is good to know someone else has experience of such things, although my vets own dog has IMPA she responded fairly quickly to treatment & altho on a low dose of preds is pretty much back to normal.
We had started to reduce the preds again but when we got down to 7.5mg he went very lame so dose was increased again & vet has added in mycrophenalate aswell as the atopica (although that had been reduced to 100mg/day. The vet was concerned that whatever triggered his AI initially may still be affecting him hence why he's not responding so well to treatment.
We both feel that the digestive issue (probably leaky gut) is highly likely. Vet said the specialist she's in contact with is really unhappy about the raw diet, I have agreed to try a high quality kibble but not the hills z/d as I don't think this will be of benefit. I have started on kefir & he's been back again today for another blood test as his liver enzymes (not suprisingly!!) are not good & wbc count is still really high (he's just had another course of antibiotics for poss infection). Thank u for confirming again that this disease can take some time to get under control, we have decided to preserve for now as although he's not a very happy chap he doesn't appear to be in pain.

Rachel
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Jo CIMDA

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Re: Diet & AI
« Reply #5 on: December 29, 2017, 07:12:15 PM »

Hi Rachel

I am pleased to know that you are continuing with treatment.  It is worth giving it all you can because IMPA has a good remission rate.

It is worth going along with your vet and trying the diet they are recommending.  It shouldn't do any harm and as they are convinced it is diet related then it might just help matters.

Good luck
Jo


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Rachel Penfold

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Re: Diet & AI
« Reply #6 on: January 03, 2018, 02:24:00 PM »

Thank you, we have changed his diet so hoping this may help.
Back again to vets again next week for another blood test & urine sample as vet has said urine infections are not uncommon with all his meds.
He does seem very slightly brighter although his aggression to our young dog has increased again 😔
So we shall soldier on for now

Cheers Rachel
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Catherine

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Re: Diet & AI
« Reply #7 on: January 03, 2018, 03:37:08 PM »

Have you tried a daily cranberry extract tablet to try and ward off urine infections?
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Rachel Penfold

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Re: Diet & AI
« Reply #8 on: January 11, 2018, 12:13:57 AM »

Hi Catherine,
Hadn't thought about cranberry thank u, might be worth trying.
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Rachel Penfold

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Re: Diet & AI
« Reply #9 on: January 31, 2018, 12:57:16 PM »

Hi, just after abit of advice really. Our boy has now had IMPA since sept last yr. he's not quite 3yro.
Initially we did see some improvement & after a while we started to reduce his dose of preds (he was also on atopica) However he had a relapse so the dose of steroids was increased & then just before Xmas the vet added mycrophenalate so we could reduce his preds (he developed cushings & doesn't tolerate steroids well) unfortunately he has also developed an e.coli urine infection & 2wks ago had pancreatitis as a result of the mycrophenalate. He was very very poorly. We stopped the mycrophenalate & he spent the night at the vets on a drip, he also had pain relief. When he came home he was the best he's been in months, tail wagging, bright & almost back to normal. However in the last few days he's gone downhill. I think the pancreatitis is under control but he is so lame he's struggling to walk/stand up etc. I know he's in pain & he's so unhappy, his quality of life is zero.
At mo he's on 10mg pred p/day. 100mg atopica p/day & Antibiotics.The vet has given us chlorambucil to start. & last night we started on gabapentin. (Have also started on cbd oil) We are back at vets tomorrow. I understand this AI is painful & can take a long time to recover from but we are reaching the point where we don't know if it's fair on him to continue any longer. I know u can't make any decision for us! But I'm really struggling at the mo with knowing what to do for the best. What's the recovery rate for AI? We are under no elusion that if we get him thro this he will prob be on meds for life & wont make old bones. I just feel so guilty that we have done what we thought was the best for him but ultimately he's spent the last 5months suffering with poss no chance of recovery. I'm just so confused as he did after being at vets really pick up to a more than an acceptable quality of life. Thank u for taking the time to read this long post, I just needed to 'talk' to someone that has been thro it.
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Jo CIMDA

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Re: Diet & AI
« Reply #10 on: January 31, 2018, 01:43:16 PM »

HI Rachel

I am sorry your boy is having these problems.  Is there  any chance you could take him to see a specialist? 

Reading through your postings, it is very difficult to differentiate between the effects of the drugs, which can be numerous,  pancreatitis, and relapses of IMPA.  I feel a new vet with a lot of experience of treating inflammatory AI diseases needs to look at him and perhaps strip back drugs and possibly introduce another, such as leflunomide.

I don't know how much a Mexican Hairless dog weighs but do some research to check that he isn't having too much Atopica, and also check the dose of Chlorambucil he is having. 

The recommended immunosuppressive dose for Cyclosporin (Atopica) is:  Empirical doses generally range from 3-6mg/kg twice daily or 5-7.5 mg/kg once daily.  Chlorambucil:  0.1-0.2mg/kg once daily.  Dosages are generally rounded to the nearest 2mg. Plumb's Veterinary Drug Handbook, Eighth Edition. 


IMPA carries a good to excellent prognosis and I have known many dogs to achieve long term remission and lead a normal life, living well into old age.  This is why I would like you to get someone else to look at him to study his drug history and start again. It is sad to know he is like this when he should be in remission by now.   Relapses can and do happen, but being on the right  drug regime is key to eventually achieving remission.   He was on far too high dose of preds to start with and this will build up within his body, and also this makes it more difficult now to give immunosuppressive doses of prednisolone if he relapses. Prednisolone is a wonderful drug if it is used correctly.   So many of the newer immunosuppressive drugs cause nausea and depression.  Prednisolone causes muscle weakness and sometimes lameness if the ligaments are stretched, and depression if the body is overloaded with the drug. You need to separate all the symptoms and know what is causing what, and take it from there.  This case needs a internal medicine specialist or a vet who has lots of experience and success in treating AI dogs with immunosuppressive drugs.

I believe you can get him through this.  He is a young dog with  IMPA. If it is dealt with properly I don't see why he can't achieve remission but just trying this drug and that, is not going to achieve this.  You need a good solid drug regimen that can be tailored to your boy to enable him to achieve remission.  Is it possible to take him to see a specialist at a vet college or similar?

I do hope you are able to sort this for him.

Jo
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Catherine

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Re: Diet & AI
« Reply #11 on: January 31, 2018, 02:55:46 PM »

I have no experience of IMPA (my dog had AIHA) and some of the medication Taco has been prescribed but it does seem a lot of different medication he has been having and maybe some of the medication is not agreeing with him. I agree with Jo that it needs reviewing.

Perhaps he overdid things when he came home from the vets, so perhaps he needs to have his exercise restricted?

I know how stressful it can be with a dog with an  autoimmune disease and especially when they are very poorly and the drugs are taking their toll but I also know how things can turn around and a dog can get better and go onto to have a happy life into old age.
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Rachel Penfold

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Re: Diet & AI
« Reply #12 on: January 31, 2018, 05:22:36 PM »

Thank u both for you advice. We are concerned that he does seem to have been on a lot of meds & our vet has said as u have that it's hard to know what symptoms are AI related & which are drug related. He's coped with so much that I guess we are so worried that we are no longer doing right by him.
Our vet has been in contact with a specialist on a few occasions but they have not actually seen him.
Do you know of a particular specialist that would be worth a try? I guess our other concern (as much as I hate to say) is financial he is not insured & we are already at 3k In hindsight I wish we had gone straight to a specialist but at the time we didn't know what we would be faced with.
Re him overdoing things Catherine I don't think that was the case as he didn't do anything when he got home, I'm really careful with that as he has no muscle so he only does gentle exercise.. Apart from trips to the vets he's not been out for about 3months!
You are right stressful is an understatement especially as I keeping trying to decide whether he has had enough! Think if he hadn't have been so much better few wks ago I would have called it a day by now, but I don't want to if he still has that chance.
I have halved his dose of atopica Jo as I wasn't convinced it was helping. Haven't started the chlorambucil yet tbh I'm scared to as he's had so many drugs I'm reluctant to give yet another one. Vet has said 2mg every other day. He weighs 20kg at mo, has lost weight again. Vets tomorrow so I shall ask about the possibility of reassessing his drug regime.
Thank you both again I'm just feeling so despondent & upset at the moment 😔
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Jo CIMDA

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Re: Diet & AI
« Reply #13 on: January 31, 2018, 07:28:07 PM »

Hi

Where in the UK (I presume you are in the UK) do you live, and I will hopefully be able to tell you the best referral centre?

It is just a case of reassessing his clinical presentation and the drugs, and getting him on the right medication at the right dose.  They won't be able to do tests because of all the drugs he is on.  A specialist can't assess unless the dog is in front of him/her. It cannot be done over the telephone.

Jo
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Rachel Penfold

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Re: Diet & AI
« Reply #14 on: January 31, 2018, 10:45:04 PM »

Hi Jo, yes uk we are in Rutland. Our vets is linked to Nottingham vet school don't know if there is a specialist based there.
I know the advice our vet got over the phone obviously was helpful but yes I agree they really do need to see the animal.
Thank u again
Rachel
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