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Author Topic: Multiple medications  (Read 935 times)

klyren

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Multiple medications
« on: April 06, 2018, 08:36:59 PM »

Toby my 10 year old Min pin was diagnosed with non regenerative IMHA back in Oct he weighs 4.9kg. Since then he has been on 12 mg pred, end of Nov his Atopica was increased to 50 mg BID and then mid Dec 1225 mg BID mycophenalte was added to his medication regime. My concern right now is that he is no longer tolerating all these immunosuppressive drugs. He has had to be on antibiotics three times since Jan. He is recovering from a terrible bout of diarrhea (he has had chronic loose stool since introducing the mycophenalate). I have also noticed that he always appears bloated especially after he eats. His appetite isnt terrible, he eats all his breakfast but then wont always finish his supper. Since Jan his PCV has been staying around 28-30. It was 28 on Tuesday. I would like to start weaning him off some of these meds but my vet and I worry that his PCV will drop. I just dont like what the meds are doing to him. I feel like its a catch 22 and if I stop the meds his PCV will drop but if I continue with the meds they will slowly kill him. Oh I should also add that he has significant hair loss on his belly. Any advice would be appreciated!
« Last Edit: April 06, 2018, 08:48:02 PM by klyren »
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Jo CIMDA

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Re: Multiple medications
« Reply #1 on: April 07, 2018, 09:01:47 AM »

Hi and welcome

I am sorry Toby has  had IMHA and is still on high doses of immunosuppressive drugs.  I don't think there can be any doubt that Toby is suffering from all this medication.  Generally, pred is started at 1mg/kg/12hours.  This is usually an adequate immunosuppressive dose.  The dose is then gradually reduced over a period of months.  Please look at the example immunosuppressive protocol below.  It is the best I have come across and it can be confidently used as a guide and tailored to the individual. It is essential to keep the dog on the starting dose until good improvement in PCV is seen and then reduce. 'The goal of therapy is to use as much as is required and as little as possible for as short an amount of time as possible'   Ref:  Plumb's Veterinary Drug Handbook, eighth edition. 

Toby has been on  an immunosuppressive dose of preds since October and this is far too long.  He has probably coped with this as well as he has because he is a small dog.  Larger dogs can't cope with being on immunosuppressive doses of preds for this long. So in that respect he has done really well.   In addition to this, he is on Atopica (Cyclosporin) which can cause the dog to feel very sick and unwell.   

As an immunosuppressant, 'Empirical doses of Cyclosporin generally range from 3-6mg/kg twice a day or 5-7.5mg/kg once a day'. Ref:  Plumb's Veterinary Drug Handbook, eighth edition.

Mycophenolate is also being used as a combination drug but there is still limited experience in veterinary medicine, also the side effects can be severe gastrointestinal signs with diarrhoea, vomiting and anorexia, so the current symptoms you are seeing could be the effect of this drug alone or a combination of Atopica and/or pred.      'The usual immunosuppressive dose of mycophenolate is 10mg/kg/every 12 hours but this can be increased to 10-20mg/kg/12hours depending on the disease.'   (Ref:  Plumb's Veterinary Drug Handbook, eighth edition)

High doses of these drugs do not make the treatment better.  It has to be the correct dose, and overdosing only causes more, and often serious, side effects. 


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.



Has Toby had anything to protect his stomach such as omeprazole or ranitidine?  If he hasn't then this also might be the cause of his tummy pains and he may have a gastric ulcer which can bleed and cause regenerative anaemia.   A dog on steroids should be receiving a gastroprotectant.  Also, when a dog is on steroids they can be prone to pancreatitis, but the blood results should indicate pancreatitis.     If Toby were mine I would want him on Denamarin or SAMe and milk thistle to help his liver to cope with all the drugs. longer

When a dog has been on immunosuppressive doses of preds for a long time it can cause bone marrow suppression.  Anecdotally, the PCV often plateaus around 28-30% and it is not until the preds are lowered that you will see the PCV start to rise, so I think you are very justified to feel that the medication is causing Toby's current clinical signs; and even if they weren't he could not stay on these high doses of so many potent drugs any longer because ultimately the side effects become more of a danger than the autoimmune disease they are treating.

With all these immunosuppressive drugs you can be sure there will be no immune destruction of the red cells going on because his immune system is being totally knocked out - and this is the purpose of using these drugs but there comes a time when the drugs have to be lowered if the dog is to survive.

If Toby's vet won't take this on board and significantly lower the drugs then you should get a referral to see an internal medicine specialist.  Your vet could always telephone one of the vet colleges for advice, but it does need to be addressed now.

Good luck with your vet.

Jo


 
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Jo CIMDA

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Re: Multiple medications
« Reply #2 on: April 07, 2018, 09:16:09 AM »

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 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 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.
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klyren

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Re: Multiple medications
« Reply #3 on: April 08, 2018, 09:44:03 PM »

Thanks for the reply. I will be bringing this info to his appt this week to discuss with our vet! He is on famotidine for his stomach protectant and does to sulcrate as well
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Jo CIMDA

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Re: Multiple medications
« Reply #4 on: April 09, 2018, 11:02:28 AM »

Good luck with your vet this week.

Jo
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klyren

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Re: Multiple medications
« Reply #5 on: April 13, 2018, 08:44:05 PM »

So we ended up having to take Toby back to the vet on Tuesday evening. He could barely move, temp of 39.9, tachypenia and was hardly responsive. The vet on call did a comprehensive blood panel it showed that his WBC were extremely low, he had crystals in his urine, his HCt was 28. the vet on call was not sure what cause his sudden change in behaviour she is assuming he may have had a seizure however, she is unsure. His was d/c home with new anibiotics to combate the UTI and another to help with his diarrhea. The vet is also not overly sure why there was such a large drop in his white cell count (it has been good since his diagnosis). He was acting different yesterday (just laying in his bed, trembling, breathing fast and not wanting to move). He was better by the evening and today his brighter. He still is quite lethargic but he is eating his food. Thoughts?
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Jo CIMDA

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Re: Multiple medications
« Reply #6 on: April 14, 2018, 10:09:09 AM »

HI

I am sorry Toby has been very unwell.

Has the vet decreased Toby's preds yet?  I cannot see how a vet thinks that  leaving a dog on high doses of preds for this duration is good and not know that it is highly likely that the preds and other drugs are causing extreme adverse effects and are more problematic  than the AI disease.  The UTI and gastrointestinal problems are common,  and the low white blood cells occur when a dog is on prolonged, high doses of steroids.  See this extract:

https://endocrinevet.blogspot.co.uk/2012/04/how-glucocorticoids-affect-complete.html

The major acute effect of steroids on WBCs is to cause "washout" of marginated neutrophils and monocytes from periphery into circulation. Decreased amounts of lymphocytes (peripheral) and eosinophils are seen as glucocorticoids can sequester these cells into the lungs and spleen and prompt decreased release from the bone marrow. When administered chronically at high enough doses, glucocorticoids can cause involution of lymphoid tissue (1,2).


I think you should get a referral to a specialist or another vet who has more experience in treating AI disease and knows more about the serious side effects of the drugs.  If you live in the UK and this is possible, and you would like to know where a good vet or referral practice is then please let me know the area in which you live.

These immunosuppressive drugs are essential to bring the AI disease under control but there comes a point when they do more harm than good. 

I know you are in a difficult position but there are so many vets that just do not understand how to treat autoimmune disease or have the experience required to have a favourable outcome.  It is, unfortunately, a common problem.  These drugs have done their job but now they are poisoning Toby.  You cannot suddenly take Toby off of the preds but they can be significantly reduced.  Please find a vet who has more experience and knowledge and who is willing to work with you.

Jo

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klyren

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Re: Multiple medications
« Reply #7 on: April 14, 2018, 03:56:11 PM »

Toby has been seeing an internal medicine vet she was the one that prescribed all his medications. My local vet is a new vet and she has been trying to get a hold of the internal medicine specialist with no luck. I have spoken multiple times with my vet that I would l like to reduce his meds but she is still hesitant. I live in Canada but I appreciate your help. I will continue to try and get my vet to reduce his pred.
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Jo CIMDA

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Re: Multiple medications
« Reply #8 on: April 14, 2018, 04:56:55 PM »

Hi

Toby has been on high immunosuppressive dose of preds for 6 months!!!!!  The only reason why he has got away with this high, prolonged dose of steroids so far is because he is a small dog. They cope so much better with high doses than larger dogs.   What has your vet got to lose by significantly reducing the pred dose? 

Even if Toby has something else going on it is nonsensical to keep him on this dose of preds any longer. I do not understand what the vets are afraid of because clearly his immune system is very suppressed so there won't be an immune destruction going on at this time. Is the specialist thinking she can keep Toby on this dose forever?   If the drugs are reduced and in a little while he shows signs of a relapse then they will have to think again but at this time the major problem is the drugs.  It is more likely if the preds are reduced you will see an improvement in Toby in two to three days and this improvement will continue and as it does his HCT should increase too.

Look at the Prof Day's immunosuppressive drug protocol and compare it to the treatment Toby has received.  If something isn't done soon it might be too late.  Sadly I have just received an email from someone in a similar position and she has told me her dog didn't make it.  I am seriously thinking about writing to the Royal Veterinary College and informing them about the lack of knowledge vets have when treating dogs for AI disease. This lack of knowledge  is a world wide problem.

18 years ago my girl died because the preds dose was too high and she was being treated by a specialist. I told the specialist the dose was too high and she told me if I lowered the dose I would kill her, so I listened to the specialist, I kept to the dose as prescribed, and my Bonnie died as a result.

 The title ' Veterinary Specialist' should mean they know how to treat a dog, but anecdotally it is often proved otherwise.  Common sense, as well as veterinary training and experience, should be used when treating animals but sadly the former is often lacking and the vets are blind to what their eyes are seeing eg., the presenting clinical signs, and evidence from the blood results. 

No dog should be on an immunosuppressive dose of preds for 6 months.  In addition Toby is also on mycophenolate and Atopica. How much immunosuppression does a dog need?  The dose of these 'combination' drugs may also need to be lowered in order to reduce the awful side effects Toby is having. 

Your own vet is a qualified veterinary surgeon, and perhaps it is time for her to take responsibility and reassess the drugs Toby is on and make an informed decision.

I am so sorry you are having this problem.  I am also sorry for being very direct, but inappropriate treatment is probably the biggest reason why a dog gets into difficulties after a period of time, following drug administration.  Please talk to your own vet again and  ask her to do research, and for her to have the confidence to deal with the situation in front of her.   If the specialist hasn't seen Toby recently then she cannot know the full situation. 

Once again I am sorry for being so honest and direct. 

Wishing you the best of luck.

Jo
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klyren

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Re: Multiple medications
« Reply #9 on: April 16, 2018, 10:39:12 PM »

No thank you I appreciate your honesty so much! I will be speaking with my vet and I will be saying its time to start reducing. Like you said right now what does he have to lose! its worth a shot. He will be closely monitored while we reduce. I will let you know the outcome. He has an appt coming up very soon, we will be discussing this. Thanks again for your advice!
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