Introducing myself & Tara

[melliemoo]

Hello 

Firstly, just wanted to say thanks to Brooke Roberts for telling me about this forum

Our 3 year old GSD was diagnosed with immune-mediated Polyarthritis on December 14th.  She randomly started limping on Wednesday 6th, got increasingly more poorly from then (even though we saw the vet on Saturday 9th) until she was admitted for tests (joint taps being one of them) on Monday 11th December.

Initially, she made a small improvement on her cocktail of 60mg Prednisone, antibiotics, Tramadol and Pardale (paracetamol), but fell very poorly again on 23rd December.
She was vocalising a lot that day and struggling to walk, she was having great difficulty putting any weight on her left front leg - the center point of all of this.
I was starting to worry as by this point, she was off the Tramadol and antibiotics and was due to drop to 40mg Pred the following day.
Finally that evening, she collapsed while trying to get up for her tea so we rushed to to the vet - they gave her IV methadone for the pain and put her back on a course of antibiotics, Tramadol and told me to put all her meds back 7 days.
That trip to the vets was the most horrific I have ever experieced, as we had to bring her home on a stretcher.  Even after the Methadone, she was feeling so delicate and went into a mass panic when we tryed to lift her off the table to bring her home.  She was trying to bite people and was panting and freaking out.  We were told there and then by Laura the vet that Tara would have a heart attack and die if she didn't calm down!
Finally got her home, settled off the strecher and calm within 20 minutes....phew!

We slowly started to improve from that point, the next morning (Christmas Eve) she got up on her own with no vocalising and nudged my partner, who was sleeping on the sofa by her side. By New Years Eve she was showing signs of her old self by picking up toys and pinching them off our other dogs.
She finished her Tramadol by 2nd Jan and antibiotics by 9th Jan.

We did our first Pred drop on New Years Eve down to 40mg.  We dropped again to 20mg 5 days later (on 5th Jan) and then to 20mg every other day from 9th Jan.
All was ok - on the weekend of 13th & 14th Jan, we even filmed her acting completely normal.  Carrying a ball in her mouth, trying to jump about and rolling around on the floor.  Exactly one month on from her diagnoses and witnessing her screaming with every step she took - we couldn't believe it!

She finished her Pardale last Tuesday (16th Jan - a non Pred day)
I noticed on Wednesday that she lifted her back left leg a few times and sat down in a weird way.  She had been on a short lead walk that evening (she is a working shepherd who competes in sport, the youngest of our pack of 4 and was getting restless, having ripped up 2 beds in a week), so we put it down to that.  I gave her her 20mg Pred that night and all seemed ok.

Last Thursday (18th), all seemed ok.  It was the first night of having no meds at all.  She was her normal playful self.  No signs of lameness, pain, anything.

Last Friday morning (19th) she couldn't walk.  That front left leg again, around the ankle seemed to be the center point once again.  She was squeaking in pain and looking miserable.

I rang the vets to speak about more Pardale (maybe she came off the painkillers too soon?), but Laura wasn't keen on that and told me to up her Pred back to 1 a day.  As she was due one that night anyway, Laura told me to give Tara 1 x 500mg paracetamol to tie her over until her Pred that evening.
I went home at lunch and she was definately worse.  I gave her the paracetamol and went back to work, knowing that my partner would be home for the rest of the afternoon an hour later.  By the time I got home at 6pm, you could tell that the painkiller had kicked in.

Over the weekend, she continued to be quiet, walking slow and sad, but there was no vocalising of pain.  I gave her 20mg Pred on Saturday night but wasn't happy with her response, so decided to up it to 40mg on Sunday.  The facebook group I am on mentioned its trial and error with the Pred dosages.

On Monday, she was back being able to barely walk and vocalising in pain with each step.  We got her into the vets that afternoon and saw the practice manager, Richard, who had initially seen Tara on December 9th and admitted her for the tests on December 11th.
Her care from that point was then taken over by Laura, a younger vet, who has been amazing but in hindsight, doing everything by the book.  She has told me on Friday that if Tara didn't improve over the weekend that we would have to go down the chemo route to suppress her immune as the Pred obviously wasn't working.
This, I knew I would try to argue with, having been told its trial and error getting the Pred dosages right.

Richard on the other hand, looked at her with calm, experienced eyes and explained that the Pred was working as we has seen results of it, we even showed him the videos of her from the previous weekend acting a fool and loving life once again.
He decided we start the plan from scratch again, with 1/2 the dosage of Pardale and continue on, as there was no sign on infection or temperature increase.

I posted on the facebook group Tuesday morning and a few people commented that her Pred drop seemed too quick.

Initially she was on 60mg for 10 days (extended to 17 overall due to her infection), 5 days on 40mg, 4 days on 20mg then 20mg every other day - we were 2 weeks into that before she relapsed.
I don't know and probably will never know what caused her relapse - I know the Prednisone would have played a huge part, but could it also have been down to her being too active or the fact the temperature dropped?  Even Richard couldn't say for definite.

I've decided this time to do 20 days on 60mg, then minimum 15 on 40mg and 20mg.  I don't want her relapsing again and I feel that her doing 17 days on the high dosage before was the game changer for us

Currently, she has been back on 60mg for 3 days (4th dosage due tonight)  She was also on 1/2 Pardale twice a day since Monday, but I upped that to 1 tablet twice a day from last night as she was squeaking slightly again.  Today she vocalised very minimally when getting up, but once up is walking with no lameness or pain.

The first time round, the pain/discomfort went quite quickly, but we assume that from from being on the Tramadol.

I've decided to keep her on 1 tablet of pardale twice a day until at least Sunday just to see if that helps her more.

I am also hoping we see signs of her picking up again soon - last time she was fighting an infection and temperature so it took about 2 weeks before she started to really improve.

I feel like, just from Monday and Tuesday, that I have learnt so much more about this condition - just from calming words with Richard, who assured me that I will start to notice her triggers and will know when to tweak her Pred dosages and that it most definately is a trial and error game.
The group, especially Brooke and a lady called Olaf's Mum, have provided me with so much info and have reassured me that what we've experienced is normal.

I now just feel like I we can fight this again and take control of it more this time.

I am so grateful for having been pointed towards this forum and I'm looking forward to learning more and being able to help others as my experience increases

Sorry about the HUGE intro, but that's our story - so its a big hello from Me (Mel) and our little girl Tara xx

[BrookeR]

Hi Mel & Tara,
Its great to see that you've joined the forum 
You will greatly benefit from reading through the info here and following other people's stories who have been through similar situations. So many lovely people with experience in these horrible immune mediated diseases, who have banded together to help each other and our furr babies.

I'm so glad to have been able to help point you towards this forum. I don't know how I would have been able to get through all I have been through with my staffy Pep if I hadn't by chance stumbled across it.
I'm forever grateful to Jo and everyone else on here for sharing their stories and for listening.

[Jo CIMDA]

Hi Mel and Tara, and welcome

Tara has really had a bad time with IMPA, and it has been a dreadful experience for you too. 

The good news is the prognosis for IMPA  is good to excellent, but the drug regimen is crucial to the outcome and achieving remission. 

From your account of events it is clear that the drug regime has not been ideal and there is no surprise that Tara relapsed.  If you look at the immunosuppressive drug protocol below by Prof Michael J Day (one of the world's top veterinary immunologists) you will see it is better to take each stage of reduction much slower.  If the drugs are reduced too soon, thereby releasing immune cells, there will still be active immune cells that are programmed to target the synovial fluid in the joints and the destruction will start all over again.

I don't know how much Tara weighs but she should have started on  1mg/kg/12hours prednisolone.  The problem that you may find now is there will be a build up of cortisol in her body and at this stage she may not tolerate immunosuppressive doses of preds.  Only you or your vet can assess how she is coping with the side effects of the preds.

It is quite usual to introduce another immunosuppressive drug to work alongside the preds, and the tried and tested 'combination' drug is Azathioprine.   By using another drug, in combination,  you can lower the steroids perhaps sooner than the protocol, thereby reducing the side effects.

Pred and Aza was always a combination drug of choice but these days there are several other immunosuppressive drugs such as Cyclosporin, mycophenolate etc..... to choose from,  but personally I feel if a combination drug has to be used then pred and Aza is a good place to start. 

Have a look at the information below and most importantly the example drug protocol.  You can take this to your vet and if necessary let him do the research on Prof. Michael J Day.  You won't get a better protocol to use as a guide, but it has to be tailored to the individual taking into consideration resolution of the primary disease and also the side effects, which can be a significant problem.   Being a larger dog, Tara may not tolerate the side effects as well as a smaller dog and this is another reason why a drug like Azathioprine might be included in her drug regimen. 

Try to limit the pain relief drugs that have to be processed through the liver. Also it might be prudent to add Milk thistle and SAMe to her regimen to help the liver through this time. 

If Tara isn't on a gastroprotectant to protect her stomach from the excess acid that the preds produce, then she should be.  Ask your vet for either omeprazole or Ranitidine.  This will prevent a stomach ulcer from developing. Tara doesn't need other  preventable complications. 

I do hope you see good signs of recovery very soon.
Jo



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 Day BSc, 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.
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.
"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.

[Jo CIMDA]

......Further information:

Treatment for inflammatory/systemic Autoimmune Disease

Excluding autoimmune diseases where hormone replacement only is required, most of the diseases are treated by significantly suppressing the immune system in order to stop the destruction.  There are only a few exceptions to this.
The drugs most commonly used for the treatment of autoimmune/immune mediated disease are steroids (corticosteroids), such as prednisolone.  These may be used as the sole immunosuppressive agent or used in combination with cytotoxic drugs, such as Azathioprine. Cytotoxic drugs are used in human medicine to prevent the body rejecting transplanted organs. Many vets can be reluctant to use azathioprine with prednisolone as a combination therapy to treat autoimmune disease but there is certainly value in using a combined treatment as azathioprine increases immunosuppression and generally allows the steroids to be weaned down in the shortest possible time whilst maintaining a good level of immunosuppression.  It can make a huge difference to the outcome, and in some cases it makes remission more achievable.
All drugs have the potential to cause side effects and the major concern for treating animals with high doses of steroids and other potent drugs are the unacceptable side effects that may occur.  It is a fine balancing act between bringing the disease into remission and the side effects of the drugs.  All of the above drugs have the potential to cause a degree of liver toxicity but when the drugs are reduced the liver will recover. It has to be stated that without these life- saving drugs, in many cases, the dog would die, but the objective is to use the minimum dose to control the disease, for the minimum duration of time. However, the dose has to be 'immunosuppressive' eg.  Prednisolone 1-2mg/kg/every 12hrs usually starting at 1mg/kg/12hrs (Plumb's Veterinary Drug Handbook). If this dose does not produce the desired effect it can be raised. The action of prednisolone is rapid and at times it works like a 'miracle drug'.  Note: It should be given with food to minimise stomach irritation.
If the dose is too high the side effects may cause other major problems, if it is too low it will not control the disease or achieve remission.  One of the most common accounts are when a dog has been on immunosuppressive doses of prednisolone for too long and they start to display overwhelming signs of iatrogenic Cushing's syndrome (see below) and very often the clinical progress they have made in combating the disease has reached a plateau and the dog now appears to be weak, off their food and quite depressed. Prolonged, high doses of prednisolone can also cause bone marrow depression and the red blood cell count can decrease. These clinical signs can cause confusion for the vet and owner, and a relapse of the autoimmune disease is often suspected. It is not unusual for the steroids to be increased when in fact they should be decreased. 
Azathioprine is usually tolerated well, but as with all drugs individual dogs can be affected in different ways.  Side effects can include reduced bone marrow production, but this is rarely a problem unless the dog is kept on this drug for a long time. In contrast to prednisolone which has a rapid effect on the immune system, azathioprine takes at least 10 days to have some effect and approximately 4-6 weeks to reach its full potential. 
Note:  Azathioprine and all other cytotoxic drugs should be handled with extreme care. Cytotoxic drugs should not be handled by pregnant women.  Rubber gloves should be worn and the tablets should never be split or broken.
Atopica  (cyclosporine) is licensed for treatment of atopic dermatitis in the dog but it's increasingly being used as an immunosuppressant in 'combination' treatment with prednisolone and azathioprine for systemic autoimmune disease, despite the drug sheet stating   'It is not recommended to use other immunosuppressive agents concomitantly'.  I have known many dogs on this triple combination treatment that have eventually become overwhelmed by the side effects of the drugs and the outcome has been poor.  It may be worth, initially, trying a more simple approach to treatment, using immunosuppressive doses of prednisolone, before embarking on a 'prescription overkill' that may prove to be a difficult,  and an unnecessarily heavy drug regime for the dog. Human research suggests that cyclosporin may also encourage abnormal cells to become cancerous and perhaps even grow more aggressively. Scientists are now looking for ways to block this tumour-promoting effect of cyclosporin. (Clinical Pharmacology Made Incredibly Easy by Lippincott, Williams & Wilkins)
It must be accepted that sometimes these 'heavy' drugs have to be used, especially if the dog is not responding to treatment; and sometimes an additional drug can make all the difference to the recovery of the dog. In these cases the side effects have to be accepted as a 'trade off', in fact the dog may tolerate it very well.  However, there may be no need to prescribe combination drugs when there is a good chance that using immunosuppressive doses of steroids, and following the correct drug regime, may be all that is required to bring the disease under control.  The severity of the disease has to be taken into consideration when deciding on which combination drug regime to use, but more isn't necessarily best, and introducing one combination drug at a time would limit the side effects for the dog.
In addition to drugs used to suppress the immune system, preventative measures such as administering antibiotics to prevent infection, gastroprotectants to avoid stomach ulcers, and low dose Aspirin to minimise the risk of thromboembolism and DIC (disseminated intravascular coagulation) may be given. 

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.