Recently diagnosed IMPA

[RosiesMum]

Hi,
A friend directed me here, and the information available is fantastic - thank you.
I have an 8 year old springer who has been off colour for about 3 weeks. First vet visit 3 weeks ago showed temperature of 39 so she had anti-inflammatory injection which she responded to pretty well. She also had blood tests which other than a slightly low white cell count (but still within normal range) showed nothing to worry about. She's very nervous at the Vets so this obviously doesn't help with her temperature!
Last Friday she went downhill quite rapidly - very quiet and lethargic so back to the Vets and temperature now 40. Another injection, and back next day for further check - another rise in temperature to 40. 2 (104.3) so she was admitted to the Vets and placed on IV fluids, anti-inflammatories and methodone. Further blood tests done and sent off to Specialist Lab for analysis - inflammatory marker was through the roof, but other than slight neck pain she wasn't giving anything away (she's a very stoic little girl)! However, every time anti-inflammatories and pain meds wore off her temperature shot back up. My wonderful Vet noticed a very slight swelling in her right ankle so did joint taps on both ankles - results have indicated IMPA. She was allowed to come home on Thursday and current meds are:
Prednisilone - 15mg twice a day (she weighs 14.5kg)
Ranitidine
Synuclav (antibiotic)
Gabapentin
Tramadol

Looking at protocol this seems to be OK - no other immunosuppressant at the moment so not sure if I should query this?

Other questions I have are about exercise, food and vaccinations. Clearly, at the moment we are not exercising her physically as I think she's pretty uncomfortable, and also very spaced out with the meds - what advice could you give going forward? Obviously concerned about her compromised immune system, but she's a very active dog usually so want to try and get the balance right.
She's currently on an 80/20 kibble diet (raw feeding not an option) which she loves and has suited her very well up until now - I'd be reluctant to change unless advice is to do so (she's intolerant to rice). She's due for annual vaccinations in about 3 weeks - haven't discussed with the Vet yet but it doesn't feel right for her to have them whilst she's fighting this too? What do other people think?

Other background information - she has mild hip dysplasia which was diagnosed about 4 years ago and has been managed with hydrotherapy and Chiropractor treatment (no regular pain relief).

Thanks - sorry for the long post!

Jan

[Jo CIMDA]

Hi Jan and welcome

I am sorry that your girl has IMPA.  At least now you have a definitive diagnosis and treatment has started.  The good news is IMPA responds very well to immunosuppressive doses of steroids, so I hope you see good improvement very soon. 

She is on the correct dose of prednisolone but the duration is crucial to the outcome. If the dose is reduced too soon then a relapse is likely.
See the protocol below:

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.


Prof Day is one of the world's leading veterinary immunologists and the protocol above can be confidently used as a guide.  It is the best I have come across.

Ranitidine is a gastroprotectant, so this is good. It will help protect her stomach from the excess acid that the steroid produce.

Tramadol and gabapentin is likely to sedate her and you may find that these drugs may not be necessary as the prednisolone is also an anti-inflammatory and usually the dog responds very well and the pain is considerably less once the initial doses of prednisolone have been given. 

At the moment, even though she is on antibiotics,  I wouldn't take her to populated areas where she may be likely to pick up infections because her immune system is significantly suppressed.  As the steroids are reduced you can start to take her to the park etc.   Also, it may take a couple of weeks after starting treatment for the synovial fluid within the joints to replenish and until this time her joints might not have enough lubricating fluid to provide cushioning.

Personally, if her food suits her I would leave it as it is and if you want to change it then wait until she is better. 

As for annual vaccinations, there is no need to vaccinate annually, in fact if a dog has been vaccinated with the core vaccines as an adult it is likely that they will have immunity to these diseases for life.  Take a look at the WSAVA vaccination guidelines website.

http://www.wsava.org/WSAVA/media/PDF_old/WSAVA-Owner-Breeder-Guidelines-14-October-2015-FINAL.pdf   Prof Day is the Chairman of the Vaccination committee.

Vaccinations should never be given to a dog that has recently been on prednisolone.   A couple of years ago I attended a seminar given by Prof Brian Catchpole at the Royal Veterinary College.  I asked him if dogs that have been diagnosed with an AI disease should ever be vaccinated again, and he immediately said "NO".  He went on to say that the decision to  vaccinate should be based on a risk/benefit assessment, and dogs that have a genetic predisposition to AI disease the risks definitely outweigh the benefits.  Given, I presume,  that your girl has been vaccinated every year of her life, she is most likely to have immunity for at least 9 years if not for the duration of her life, then the decision to vaccinate again, or not, should be relatively easy for you.  If you want proof of immunity, when she is better you can have an antibody titre test done to see if there are a antibodies to the core diseases that are vaccinated against.  Any detection of antibodies correlates to immunity.  Leptospirosis vaccine is a killed virus vaccine and this is more likely to trigger an AI disease because they have to use chemicals to activate the immune response.  Also, lepto is not a common disease and there are over 200 different strains and there is only a vaccine for about 6 of them.  Also, because it is not a live vaccine it does not produce antibodies and only lasts between 3-6 months and not the year that we are lead to believe.  This information can be found on the WSAVA website.

I do hope you have seen an improvement in your girl but it may be difficult to tell if she is having drugs to sedate her.  When these are withdrawn you will hopefully see a remarkable difference.

Jo

[RosiesMum]

Hi,
Thank you so much for your reply.
She's definitely feeling more comfortable - showed some discomfort in her neck and elbows when she saw the Vet yesterday, but we are reducing the dose of both gabapentin and tramadol with a view to her coming off them by the weekend.
The steroids seem to be making her shaky, and her heart & respiratory rate increase considerably for about 2 hours after she's taken them - not easy to watch but our Vet has reassured us that it's not unusual. The Vet called today to say she's been liaising with a Specialist who is suggesting putting her on to mycophenolate as well as the steroid with a view to reducing the steroid slightly after 2 weeks.
We also discussed vaccination and Vet said she wouldn't want to vaccinate her again ever (she'd only be due for lepto this year anyway) - she said its just not worth the risk, and if necessary we can titre test. I have to say our Vets practice have been fabulous - whilst she was an inpatient their Orthopaedic Specialist came in on his day off to check on her, and they have called us regularly since she came home to see how she's doing.
Rosie's drinking for England (and would also be eating for England too given the chance!!) so we're taking it in turns to sleep downstairs with her to let her out when she needs a wee!
I didn't know anything about AI diseases at all until a couple of weeks ago so it's been a bit of a steep learning curve and I've only scratched the surface so far. I'm so grateful to you for your advice - this site is invaluable.
Thanks again.
Jan

[Jo CIMDA]

HI Jan

This is all positive news. 

Mycophenolate is being used more and more as a 'combination' drug and is getting good results however, IMPA or if she has a stiff neck it might be steroid responsive meningitis SRMA,  responds well to steroids so a combination drug might not be necessary but it will probably allow you to lower the steroids sooner.

I am so pleased your vet doesn't want to vaccinate again.  Yes you can do titre tests but to be honest what is the point when you can't risk vaccinating again anyway?  Try to keep Rosie as natural as possible and avoid all 'spot-on' or regular preventative treatments and chemicals too.   IMPA has a really good prognosis.

Jo

[RosiesMum]

Hi Jo
Rosie's been doing OK, but has been very quiet and a bit lethargic for a couple of days.
She's been off the tramadol and gabapentin since 4th August which is good news.
She seems to be struggling with the prednisone (shaking, panting and rapid breathing after taking them) so vets introduced mycophenolate as well to reduce prednisone a bit more quickly. Doses are as follows :
From 26/7 to 4/8 - 15mg pred x 2 per day (she weighs 14kg)
From 5/8 to 14/8 - 15mg pred am and 7.5mg pred pm plus.0.7ml mycophenolate twice a day
From 14/8 (for 2 weeks) - 15mg pred am and 2.5mg pred pm plus 0.5ml mycophenolate twice a day
(still taking ranitidine too)
Saw the vet yesterday - temperature 39.2 (usually around 38.5 to 38.8 at the vets as she gets herself all wound up!) but no signs of pain /discomfort anywhere - neck pain has gone. Vet advised reduction in meds as above and keep a careful eye on her.
My concern is that we seem to be reducing meds quite quickly, and possibly not in line with the protocol you kindly shared here - not totally sure how it fits with the mycophenolate though?
I'd appreciate your thoughts when you have a moment. - thank you so much.
Jan

[Jo CIMDA]

Hi Jan

The protocol your vet has proposed would not be my choice.  Anecdotally, the best protocol is Michael J Day's.  I have known this to work the best.  Reducing as quickly as you have, and reducing one day's dose much quicker than the other doesn't usually achieve remission - but this is my own experience.  You do have the back up of mycophenolate and although this is a relatively new drug to veterinary medicine, it is proving to be very beneficial in the treatment of AI disease.   I hope the mycophenolate will maintain immunosuppression whilst you lower the preds. 

The response to therapy and also the adverse effects have to be taken into consideration when deciding what drugs to use and how to reduce them.

If Rosie relapses then perhaps you should consider taking her to see a specialist or asking your vet to seek specialist advise on a treatment regimen.

Jo

[RosiesMum]

Thank you - I'm going to book another appointment with our Vet to talk things through and agree a way forward.
Jan

[Jo CIMDA]

Hi Jan

Michael J Day is an eminent professor of immunology, based at Langford, Bristol,  and his protocol can be confidently used as a guide - but it always  has to be tailored to the individual.  At all times the clinical signs of the disease being treated and any drug side effects have to be considered when deciding on a drug protocol and the protocol can be adjusted as necessary. There are no hard and fast rules - only guidelines on what is generally considered to work the best. 

Good luck with your vet.

Jo

[RosiesMum]

Hi
So Rosie has spent all day at the vets today. Took her first thing and they decided to run bloods just to make sure we weren't missing anything as temperature a little high.
I took along a copy of the protocol and left it with them to look at.
Bloods all ok and temperature settled during the day so conclusion is that meds reduced too quickly (which is what I thought from looking at the protocol).
Back to 15mg pred twice a day for at least a week and then, depending on how she's doing, a much slower reduction in dose.
If they want to do anything outside the recommmended protocol I'll be asking why - as you say depends on how she's coping but as long as she's managing reasonably well I think a relapse at this stage is far worse than any side effects she may get from the drugs.
Thanks again for all the info - feeling a bit more positive this evening.
Jan

[Jo CIMDA]

Hi Jan

It is so stressful dealing with AI disease and in addition battling with the vet but at least yours seems to be on the right track now.  It is not easy and well done for highlighting the problem.   

I do hope you see a remarkable improvement in Rosie very soon.  Just monitor the side effects of the drugs and if need be the reductions will have to be made.  Take each day as it comes.  I am so pleased you feel more positive.

Jo