Immune mediated polyarthritis

[Peggys mum]

My beautiful 7 year old std poodle has just been diagnosed with this disease. I am heartbroken, she looks so sad, she is on antibiotics for an infection and has just started oral Prednisolone.  I am thinking about some canine hydrotherapy for her, has anyone any experience of hydrotherapy in this disease.  Also, the use of steroids terrifies me, she is on 10mgs bed for five days, then to go to 10mgs once daily for 10 days, then providing she does well, 10mgs every other day.  Any advice, stories of similar cases etc would help, it is heRtbreaking to see her suffering when she is bad.  Thank you.

[Jo CIMDA]

Hi and welcome

I am sorry Peggy has IMPA.  I question the prednisolone drug regimen she is on.  When a dog has an immune mediated inflammatory disease they need to be on immunosuppressive dose of prednisolone and that is 1mg/kg/12 hours.  Please see the immunosuppressive protocol below.  It is the best I have come across and it can be confidently used as a guide.  Peggy not on anything like this dose.

The dose and duration of this treatment is crucial to the outcome.  Unless it is very similar to the Michael J Day immunosuppressive protocol the dog will not achieve remission  and a  relapse is almost inevitable. If a relapse occurs then the dog will have to go onto the correct dose of prednisolone but by then it has already received - without any good effect - a build-up of steroids.  This makes managing the side effects even more difficult, especially in a larger dog. 

The good news about IMPA is if it is treated correctly then long term remission can be achieved and the dog can lead  a normal life and hopefully a relapse will never happen - although it is always possible if a trigger is met. 

At this moment you need to limit her exercise and not work her joints too much,  so until she is over the worst and her joints have replaced some of the synovial fluid that they have lost then I wouldn't give her hydrotherapy.  Also when she is on the correct dose of prednisolone her immune system will be suppressed and she will be vulnerable to infections so limiting her time in public places is prudent.

It is a good idea to put Peggy on something to protect her stomach - see information below:

Here is some general information with a very successful immunosuppressive drug regimen that can be tailored to the individual dog.

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.

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.

Have a chat with your vet about changing to the Michael J Day protocol.

Jo

[stevenday]

Hi Peggy's mum,

There can be a positive outcome, even though it is a very painful condition and is horrible to experience.

Our little 8 month old Cavachon, Buddy, contracted the same condition towards the end of November 2017.  He started limping one day and within a week, he could hardly walk and yelped in pain when touched. He went from a bouncing little puppy to being completely still and lifeless within a week.

We took him to a Vets that hadn't treated the condition before and put him on a very high dosage of steroids. They were great and were a great help, overall, but in hindsight, the dosage was too high.

He was on the following dosage:

2x5mg Prednicare tablets twice per day
1/2 tablet of Zitac twice per day
25mg Atopica tablets, twice per day

After a month of no improvement at all, we took him to another Vets who had treated the condition.

They immediately changed the dosage to the following:

0.5 x 250mg tablet Ceporex twice per day
1 x 25mg tablet Atopica once per day
1 x 10mg tablet Omeprazole once per day
2 x 5mg tablets Prednicare once per day

After approximately one week he started to wag his tail again and started to walk on Christmas Eve, which was a great Christmas present.

He has continued to improve and his drugs are being reduced slowly:

1 x 25mg tablet Atopica every other day
1.5 x 5mg tablets Prednicare once per day

It took one whole month before there were signs of improvement and we had to have the conversation regarding whether we should allow his pain to continue. It may well have been the high dosage of steroids?

The good news is that he is virtually back to normal now. He may be on some tablets for the rest of his life, but we're just glad he's back to normal.

It's a horrible condition, but stick with Peggy and hopefully she'll be back to normal soon.

Steve

[mon67]

Hi Steve

thanks for sharing, I read the change of dosage of your dog and I couldn't spot any change in immunosuppressive dosage, actually Atopica is a lower dose, so I guess the change depends on your dog just getting better by himself.

What do you think? How did vet justified the change in dosage?
Thanks for letting me know.

Our Ripley is on Pred 1mg x k one a day, and Atopica 10mg x kg a day.

Monica

[stevenday]

Hi Monica,

Sorry for the delay in responding. Buddy is now on just a half tablet of Pred every 2 days and is doing great.

I guess the difference between the two vet's treatment, was the fact that our current vet had treated the condition previously.

Fingers crossed, he will be off the tablets altogether in 6 weeks, but he is being weened of the Pred tablets slowly and carefully.

Hope she is doing well!