Searching for erosive IMPA information

[hbandmf]

My sweet little girl has been dx with the erosive form of IMPA (verified through joint taps, radiographs and other fluid samples). It had already done moderate damage when we discovered it and has eaten away the cartilage in her knees, started in on her bone and has targeted her jaw as well. I have scoured the internet for info, which is scant, but landed on your message board. Our vet told me that the erosive form is found in 1% or less of cases and is extremely rare, thus there is a tremendous lack of research and treatment protocols here in the U.S. As such she is being treated with a protocol much like that for the non-erosive form. We started out on high dose prednisone and titrated off so we could try stem cell treatment. She had the stem cell treatment last week and has been completely off pred for 2 weeks. The voracity with which the disease amped back up after the pred stopped is awful. She lost her ability to walk again, is clearly uncomfortable and has redeveloped a jaw tremor that had disappeared when we started the pred. However, we need to try to keep her off of it for two more weeks because she is taking another medicine for 3 weeks that she can't be on the pred for, to help reset the receptors that build up a tolerance to opiates making them less effective. She goes back Monday for a checkup and to develop a treatment plan going forward if the stem cell treatment doesn't work, which will presumably include pred and another immunosuppressant. She gets acupuncture and laser treatment weekly, and we give her hemp oil which the neurologist seems to think is helpful. We would love any research studies anyone on here can refer us to or provide, as well as to gather information from others as to what they have found helpful and not helpful in their pet's treatment. We are open to any suggestions. We really want to avoid high dose immunosuppressants if possible because they are so hard on her. We have heard that licorice carries a lot of the same properties and can be helpful. If anyone has tried that, I'd love to hear about your experience with that as well. Thank you for any assistance you can provide. This dog is my world and makes every day better. I owe it to her to do the same for her.

[Jo CIMDA]

Hi and welcome

I m sorry your girl has erosive polyarthritis.  As you know erosive polyarthritis is very rare in the dog and therefore there is much less written about it.

I referenced my book Clinical Immunology of the dog and cat by Michael J Day for erosive polyarthritis,  and there are two different forms that occur in the dog, Rheumatoid Arthritis (RA)and Periosteal Proliferative Arthritis  (PPA). 

I don't know which form your dog has but my reference states treatment as Gold therapy (Chrysotherapy)  with a low dose of prednisolone  might be an option. Gold may be immunosuppressive.  It is a  class of slow acting anti-rheumatic drug (SAARD)   It can be given by intramuscular injection (Sodium aurothiomalate) or oral preparation (Auranofin).  A small test should be done before therapy is started to check for adverse reaction. 

Other drugs are methotrexate and leflunomide and possibly a newer immunosuppressive drug called mycophenolate mofetil.  Prednisolone is a marvellous drug but one of the side effects is muscle weakness and often a drug such as leflunomide is used as a primary drug alongside low doses of prednisolone.

As erosive polyarthritis attacks the collagen, I wonder if collagen supplements might be of use, but you would have to do your research and also have a chat with your vet or nutritionalist.   

This link gives treatment options and is a good source of information:
http://veterinarycalendar.dvm360.com/immune-mediated-polyarthritis-proceedings?pageID=3

I am sorry I can't give you any advice based on experience but as you say, erosive polyarthritis is rare in the dog.

I wish you all the best and hope you can find a treatment that will bring remission.

Jo

[hbandmf]

Jo,

Thank you so much for your response and for the information. We did have an RA test done and it came back negative. So I guess that leaves us with the PPA. We had a vet appointment today and I mentioned the collagen so our vet is going to look into it. We are restarting the Pred today and will be introducing Leflunomide shortly thereafter. I was astounded how aggressively and how quickly the disease attacked when we titrated her off for the stem cell treatment. I am curious how to keep the weight gain down when she starts the pred again. She gained so much weight last time, even with us restricting her diet, and it hurts her to walk more than a few minutes when she does have the ability to walk, so exercise isn't much of an option. We do hydrotherapy but that is only once a week and very expensive so there isn't much of a weight loss benefit there. Do you have any suggestions?

[Jo CIMDA]

Hi

It is difficult to keep the weight off when a dog is on high doses of steroids.  It is also difficult to treat this sort of disease with high doses of prednisolone because it produces muscle weakness so it is good that Leflunomide will be introduced.

Whilst her immune system is significantly suppressed  you should avoid public places where many other dogs walk (or swim) as she can easily pick up an infection.  I would feed her 4 times a day and that way she may think she is getting more food than she really is and it may stem her appetite. Perhaps adding more veg will bulk out her meals.  Also, use a low fat diet if she is on high doses of pred because this can induce pancreatitis. I would also ask for a gastroprotectant such as Omeprazole or ranitidine whilst she is on a significant dose of preds because this will remove the excess acid and prevent gastric ulcers.   

It is the drugs that will achieve remission and until they are much reduced there isn't very much you can do about her weight.  Gentle exercise is needed because her joints might be dry and this can cause wear on her bones.
I do hope you see and improvement very soon.

Jo

[Jo CIMDA]

Hi
For your information, I  mentioned erosive polyarthritis to a vet friend of mine and she replied:

A good link:   http://veterinarymedicine.dvm360.com/recognizing-and-treating-immune-mediated-polyarthritis-dogs 

Treatment is usually the same as for the nonerosive IMPA, immunosuppression, although in some cases surgery may be performed on affected joints.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5332147/

It wouldn't hurt to try PSGAGs you would likely get improved pain relief. 

I don't know of anyone using collagen treatments, but it would not be contraindicated either.  These papers are also of interest.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222329/ http://cal.vet.upenn.edu/projects/saortho/chapter_89/89mast.htm 

Just thought I would pass on this information.

Jo

[hbandmf]

Thank you for the articles. I actually already had them all bookmarked and had previously sent them to her vet so he could be up to speed on the same articles I had read. But I appreciate it all the same. If you ever come across any others I'd be so grateful if want to pass them along. I didn't realize that about the high fat diet which was good to know because since she is so so picky about what she will eat on any given day, and refuses pill pockets, we have been concealing her pills in meat (usually deli meat) because she will typically eat that without analyzing it too much. I will need to find a lower fat way to hide her meds (peanut butter, pill pockets and all the usual stuff does not work with this one - she can smell a pill a mile away). I even have to wash my hands in between concealing a pill in something and handing it to her because if she gets one hint of a pill smell on my fingers, she will reject all food, whether it has a pill in it or not.

No one has mentioned PSGAGs to me. So I googled it. I am very interested and have questions! So the first question...on this site it says not to mix with other medications. https://www.drsfostersmith.com/Rx_Info_Sheets/rx_psgag.pdf  Is that all medications or pain medications? I am about anything that will help her be more comfortable. She has a recheck visit on Monday so I'm definitely asking about this. I see that it is a course of 8 injections. How long does it last after the 8th one is received?

I love the idea of 4 smaller meals a day. That makes a lot of sense. She is so funny - she gets right in my face, nose to nose, and just stares at me unblinkingly when she thinks I'm ignoring her cues to feed her. If I don't look back at her and acknowledge her, she starts licking my arm in further attempts to get my attention. I am definitely going to try your suggestion for tomorrow! I have one last question for the night. The vet said I could give her ranitidine but didn't have the dose handy because she was at home. What dose should I give a 17 lb dog?

Thank you from the bottom of my heart for your time and for running this forum. I am so grateful I found it. It is extremely helpful, even just reading other people's stories. No one knows what I'm talking about here so I have no one to commiserate with. The vets see the erosive form so rarely that they don't have a lot of info and our internist has a pretty fatalistic outlook about the whole thing. I am a glass half full kind of person so I don't tolerate much of his pessimism. I know her life span will be shortened but in the meantime I am going to do all I can to give her every chance to have a good life. This dog has been through two disc surgeries, four months straight of pneumonia with two hospitalizations and almost died each time, hind leg paralysis, and now erosive IMPA all in a year's time and has never once has she given an inkling that she is ready to give up. In fact, she even tried chasing some deer in the yard a couple of weeks ago. She can't really run anymore so she hopped like a bunny trying to chase them! Her internist said he couldn't believe she even wanted to try to chase them. And then he relented a little and said, "well she certainly has a lot of spirit." I'm glad he is finally starting to see how much drive she has!

[Jo CIMDA]

HI

For information regarding PSGAG, I have referenced

Plumb's Veterinary Drug Handbook, Eighth Edition:

Polysulfated Glycosaminoglycan (PSGAG)

Drug interactions:  While specific drug interactions have not been detailed to date, using this product in conjunction with either steroids or non-steroidal anti-inflammatory agents could mask the signs can clinical signs of septic joints.

There is some concern that since PSAGAG is a heparin analogue that it should not be used in conjunction with other NSAIDs or other anticoagulants.  Clinical significance remains unclear, but use together with caution.


Doses:
Dogs: For the treatment of non-infectious degenerative arthritis and/or traumatic arthritis:  (labelled dose: FDA approved)  4.4mg/kg IM (IM = Intra
Muscular)  twice weekly for up to 4 weeks. (Label information: Adequan Canine)   



This is a very informative link and I hope it answers your questions:

https://vcahospitals.com/know-your-pet/osteoarthritis-in-dogs-joint-support-and-disease-modifying-osteoarthritis-drugs-dmoads

Good link:

https://thebark.com/content/vet-advice-relieving-your-dogs-arthritis

BSAVA Small animal Formulary:

Ranitidine: 
Dogs:
Doses:  2mg/kg/every 8-12 hours  A dog weighing 17lbs - 7.7kg so the dose of Ranitidine will be about 15mg, two or three times a day.  Ranitidine has a very wide safety margin.

I love your 'go for it' attitude and why not? 

Good luck with your vet.
Jo