Hello I’m new here with a whippet puppy diagnosed with SRMA

[m6amb1]

Hello I've been recommended this forum because today my 10 month Whippet puppy has been diagnosed with SRMA today. 3 weeks tomorrow Frankie went to the vets to be castrated since then he has been very poorly. Twice in the last 2 weeks he has been admitted to the vets with a very high temperature. After a few days sent home where he has rapidly gone down hill. He is totally unrecognisable as the same puppy that went in for a simple operation. He has no life , lost lots of weight, and is a shadow of his former self. My vet referred him to Cave Specialists Vets in Taunton on Tuesday evening after another check up where his temperature was extremely high. Today I have driven the 2 hour journey and left him there where he's had an MRI and spinal tap. Tomorrow I will be driving back to Taunton to find out what his future holds. A very kind lady has given me the link to this group where I'm hoping I will learn more about this AI disease and find out what else I can do for my baby. I appreciate any help any if you can give me
Thank you

[Jo CIMDA]

Hello and welcome

I am sorry your young Whippet has SRMA.  The good news is if it is treated correctly then the prognosis is excellent.  There may be one or two relapses along the way but in general dogs who have had SRMA can reach long term remission and lead a normal life.

He should respond well to steroids (as the name of the condition implies) but the dose and duration is crucial to the outcome and achieving remission.  The best drug protocol I have come across is by Prof.Michael J Day, from Bristol University.  Prof Day is among the top veterinary immunologists in the world and this protocol can be confidently used as a guide.

A dog that develops an autoimmune disease has to have a genetic predisposition but to all intents and purposes it is a normal dog until it meets a trigger and clearly the trigger for your boy's SMRA was the procedure/general anaesthetic (drug etc) or the stress of being castrated. One of these, or all, could have contributed to him developing SRMA.  Now that you know he has a genetic predisposition to autoimmunity you must keep him as natural as possible and this means limiting trigger factors, and these include, vaccinations, spot-on treatments, chemicals, stress etc.........

Below is the protocol by Michael J Day and some general information about what to expect when treatment has started.

Usually the response to immunosuppressive steroids  is very quick, so I expect you will see a marked difference in him by the time you take him home.

Jo
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.

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.
Prednisolone:  "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.

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.

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.

[m6amb1]

Thank you Jo for so much information I really appreciate it. I collected Frankie this afternoon from Cave Specialist vets in Taunton. He is on prednisolone 4 x 5mg this evening and the same tomorrow morning and then down to 2 x 5 mg tablets morning and evening for 12 days and reducing to 1 tablet twice daily. He also has to take omeprazole 10mg everyday . I have to take Frankie back for a recheck in 2 weeks . As soon as I collected him I could see an improvement already and that was after starting the steroids last night. I am so relieved that we know his diagnosis.

[Jo CIMDA]

Hi

That is great news.

I am so pleased you can see a difference in Frankie - this is how it should be and it indicated that the drugs are working well.

Just be careful that the dose Frankie is on is immunosuppressive and follows the protocol similar to Prof Days.  If you lower the dose too soon it is possible Frankie will relapse and then you will have to start the whole immunosuppressive drug  protocol from scratch.

I don't know how much Frankie weighs but he should be started on 1mg/kg/12 hours pred and gradually reduced over a period of 4-6 or more months.

Relapses of SRMA are not unusual, especially in a young dog and the best why to try to avoid a relapse is to follow a good protocol and eek out each stage of reduction for 14-16-18 days etc...... is possible looking at the resolution of the disease and the side effects of the steroids.  It could be that the protocol proposed for Frankie might be reducing the preds too soon.

Jo

[m6amb1]

Frankie weighs 10.8 kg at present , he has lost quite a lot of weight recently . So at the moment he is taking 2x 5mg Prednicare twice a day, does this seem the correct dose at this stage? Also can I ask when I should be giving him the Omerprazole? Should I give it with his food and press in the morning or is there a better time to have the gut-protectant?

Thank you so much for all of your advice so far

[Jo CIMDA]

Hi

Whippets tend to lose weight when other dogs put weight on. The same is true in greyhounds - and I expect other sight hounds.    I think this is because they are different to other breeds.  My theory is  when a dog is on steroid therapy there will be muscle loss and because preds speed up the metabolism this is even more marked in a sight hound, and it might be that the food is pushed through the digestive system much faster and perhaps not digested normally as would be seen in a different breed. 

I hope the preds have increased Frankie's appetite so perhaps you could give him smaller meals perhaps 3 or 4 times a day if that is convenient.  Keep it low fat if possible.  You may be able to feed more carbohydrates such as oats, as these are slower to digest.

Omeprazole works best if it is given before the first meal of the day - if that fits into your regimen.

The dose of pred is correct at this stage but I am concerned if it is lowered too early that Frankie might relapse, and also a reduction of 50% is not usual practice these days. Many years ago a 50% pred reduction after 10-12 days was the norm,  but much more is known now about immunosuppressive treatment and in an attempt to achieve long term remission a reduction of 25% each time, and for a  longer duration than 12 days, seems to achieve remission more often.  Prof Day's protocol is the best I have come across and it can be confidently used as a guide and tailored to the individual. 

If a dog relapses then the preds have to be raised to an immunosuppressive dose once again and perhaps introduce another 'combination' drug. If this can be avoided then it is best because there will be a build up of steroids already in the body from the first round of treatment. 

Jo

[m6amb1]

Thanks Jo
I'm back at Cave specialist in Taunton on the 24th May so will mention this then.
Thank you again for your knowledge you've been so very helpful so far