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Author Topic: Introduction  (Read 330 times)

Catherine

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Re: Introduction
« Reply #15 on: July 18, 2018, 09:18:12 PM »

Has she stopped the 30 mg of Leflunomide once a day then? I have no experience of Leflunomide but if it does a similar job to Azathioprine I would have reduced the Preds and then stopped the Preds completely before reducing and stopping the other drug.

If she is only having the Preds now I agree with you that it would be better to keep to the same amount daily if Sophie is coping well with the medication. So 7.5mg daily and then eventually to 5mg daily rather than every other day or different amounts each day.
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dalebrook.bp@gmail.com

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Re: Introduction
« Reply #16 on: July 19, 2018, 02:27:08 AM »

Sorry Jo - yes she is still on the Leflunomide - 30 mg per day.  I assume you would still keep doses even of two days - ie 7.5mg per day?

Patricia
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Jo CIMDA

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Re: Introduction
« Reply #17 on: July 19, 2018, 01:32:45 PM »

Hello Patricia

It is good news that Sophie is doing well. 

   I agree with Catherine, and I would use the reducing protocol by Michael J Day as a guide - but you can go slower at this stage if the side effects of the preds allow.  Anecdotally, if the last stages of immunosuppressive protocol is taken slowly, on a daily basis,  it usually reaps better results and a greater chance of reaching long term remission.  As long as she is coping with the side effects then there is no rush, but no two dogs are the same and the protocol has to be tailored to the individual. 

I am not a vet so I can only give a personal opinion on what I would like to do if Sophie were mine. In an ideal situation 10mg a day can be reduced to 7.5mg a day and if all is well it is best to eek out the duration to 14 days and if clinical signs allow I would stretch that to 16 or 18 days and then reduce to 5mg per day.  Then, one option would be to reduce from 5mg every day to 2.5mg every day -  or you could go 5mg and 2.5mg on alternate days. Again I would eek out the duration of this small dose for up to 21 days. Then you can go 2.5mg every other day etc., etc..... and eventually wean off altogether.   

There is no hard and fast rule at this stage of treatment but what you want to achieve is stability and homoeostasis and when dogs are on steroids for many months, taking the last stages slower seems to give a better chance of achieving this. These low doses are having no real therapeutic effect but anecdotally the evidence shows by giving a very low every other day dose, that is very gradually weaned down,  is less of a shock to the body and as the dose is lowered the body's own cortisol will naturally start to produce the correct level of cortisol needed to function normally.

Perhaps you can discuss this option with your vet.

Jo 
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dalebrook.bp@gmail.com

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Re: Introduction
« Reply #18 on: July 21, 2018, 09:46:00 PM »

Thanks for your help, Jo.  I feel much happier about the 7.5 mg a day, so I'll discuss it with the vet - Sophie goes for more bloods tomorrow and haematology and biochemistry are both going to be done.  She just had haematology a couple of weeks ago as her PCV had gone down the time before and he wanted to check that it had gone up to her usual level which seems to be around 38.  Apart from the ravenous appetite, which I guess might have become partly a learned behaviour, her other pred side effects are not too bad, so in view of her relapse, we have been taking things pretty slowly.

Thanks again - I really appreciate being able to discuss things with you and getting your advice.

Kind regards

Patricia
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dalebrook.bp@gmail.com

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Re: Introduction
« Reply #19 on: July 25, 2018, 05:32:21 AM »

Hi Jo

Have just been to the vet and discussed Sophie's dose reduction if the bloods taken today are looking OK.  He is very clear that he thinks it should be 10 mg one day and 5 mg the next day, to help stimulate Sophie's own system.  Having looked at Michael Day's protocol, this seems to fit, as I see that the protocol has doses on every other day after the initial period of time - it is now 6 months since Sophie relapsed, so the timeline seems about right.  She is basically going to have 7.5 mg per day over the two days.  I guess I am very nervous after she relapsed when on an every other day dose, although it was 5 mg every other day, and no dose on the in between day, so much lower doses.  And she will still be on the Leflunomide, which she wasn't having when she relapsed.  What would your feeling be about going with the 10mg one day and 5mg the next? 

Her bloods are looking ok I think - Alk Phos is down from 181 to 89, ALT from 319 to 149, AST from 62 to 59, CPK has gone up from 401 to 527.  Pathologist comment:  "Ian, the liver parameters are looking improved - at these values may be due to the drugs used - induction/increased permeability.  The lipaemia may be due to the steroids?"

The haematology is: RBC 5.22 down from 5.35, Lymphocytes Abs up from .2 to .4, Monocytes Abs down from .5 to .1, PCV is .37 down from .38MCH down from 26 to 25, MCHC down from 363 to 354, WBC down from 17.1 to 12.7, Neutrophils Abs down from 15.9 to 11.4, Lymphocytes Abs up from .2 to .4.  All other results are within normal ranges.  Comment: "Ian, the RBC parameters are low normal, marginally trending down again.  The haemoglobin (even though performed manually) is probably still artefactually increased due to the lipaemia of the sample.  This HCT is a manual PCV.  The MCV is still high normal so no indication of any iron deficiency at this stage (although at end June the MCV did drop to low normal)."

Thanks again for your help.

Patricia
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Jo CIMDA

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Re: Introduction
« Reply #20 on: July 27, 2018, 10:29:13 AM »

Hi Patricia

Personally, to give the best chance of reaching long term remission,  I would still prefer to go 10mg one day and 7.5mg the next but much depends on whether Sophie is coping with the side effects of the drugs and if the long term use of preds are causing the drop in PCV.  Of course the Leflunomide may be reducing the level of PCV too. 

  I can only give a personal opinion. Ultimately you have to agree the dosage with your vet.   I don't think you have any choice but to go with your vet and hope that as the dose of preds is reduced the PCV will rise and you can then start to reduce the leflunomide.

Fingers crossed once you have weaned down the preds the blood values will return to normal.

Jo
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dalebrook.bp@gmail.com

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Re: Introduction
« Reply #21 on: August 09, 2018, 03:08:41 AM »

Hello Jo

We went with the 10 mg one day and 5 mg the next day, and Sophie seems to be doing well. 

These are her latest bloods (I have had her cross matched with a potential donor in case of relapse, so these results are included too.  Obtaining blood quickly would be very difficult in New Zealand as we don't live in Auckland.)

* Cross match See Below
RBC 5.34 L x10^12/L 5.5 - 8.5
Haemoglobin 130 g/L 120 - 180
HCT/PCV 0.37 L/L 0.37 - 0.55
MCV 70 fl 62 - 74
MCH 24 pg 20 - 25
MCHC 349 g/L 320 - 360
NRBC 1 /100LEU 0 - 2
WBC 11.6 x10^9/L 6 - 17
Neutrophils % 91 %
Neutrophils Abs 10.5 x10^9/L 3 - 11.5
Lymphocytes % 2 %
Lymphocytes Abs 0.2 L x10^9/L 1 - 4.8
Monocytes % 5 %
Monocytes Abs 0.6 x10^9/L 0.2 - 1.4
Eosinophils % 2 %
Eosinophils Abs 0.2 x10^9/L 0.1 - 1.3
RECIPIENT: Sophie
DONOR: Bella
RESULTS:
Minor Crossmatch :
There was agglutination seen microscopically for the above animals in minor crossmatch.
Major Crossmatch:
There was no agglutination or haemolysis seen macroscopically or microscopically for the above animals in
major crossmatch.
Erythrocytes: Anisocytosis 1+, Polychromasia Occ.
Leukocyte morphology appears normal.
Platelets clumped. Sufficient numbers of platelets seen in film.

VETERINARY COMMENT:
Results marginally decreased from the last bloods, but still no overt anaemia - with low normal RBC
parameters.
The lowered lymphocytes are usually due to stress/ steroids.

She will be on the 10mg and 5 mg dosage for another two weeks before any change pending another blood test.  I am wondering what the next move should be.  I understand that the 5 mg is not a therapeutic dose, so if we moved to 5mg per day, she would basically not be receiving any advantage from the pred?  And the Leflunomide would be providing control of the IMHA - is this correct?  So would the next move be to stop the pred, or would it be better to go to 5 mg every other day?  I find it all quite confusing as I don't fully understand how the meds work.

Thanks Jo

Patricia
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Jo CIMDA

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Re: Introduction
« Reply #22 on: August 09, 2018, 08:14:07 PM »

HI Patricia

The bloods are looking ok. Yes the leflunomide is the primary drug and the prednisolone will be reduced and then withdrawn.  There are several ways to reduce when you are down to a low dose and none are wrong.  It largely depends on whether Sophie needs to come off the preds quickly because of unwanted side effects or her minimal side effects allow you to take it more slowly. 

When a dog is on steroids the part of the adrenal glands that produces cortisol becomes dormant because it is being artificially provided by the preds.    The reason for reducing the pred, as opposed to stopping it abruptly, is to allow the body's own cortisol production to kick in and function normally once again.  If you don't reduce in a controlled manner the dog will become deficient in cortisol, which can be dangerous.  So, yes,  a low dose is not having much therapeutic effect but it does give adrenals the opportunity to start working normally again and many vets will want to go to every other day dosing as soon as they can but, anecdotally, it seems better to get to a low daily dose before going to every other day. 

The most obvious reduction might be to reduce to 5mg a day,  but your vet may also decide to reduce to 10mg every other day.  By going to every other day the adrenals have to start working

Other options:

10mg one day -  2.5mg next
7.5mg one day -  5mg the next
5mg one day  - 2.5mg the next  etc...........................................

 I have also known dogs, especially those who have previously relapsed,  to be reduced by 1mg at a time.  It depends on the individual case.

Jo
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