It’s been a long time- Pep having trouble with swollen elbow

[BrookeR]

Thanks jo. Lots of helpful things to think about and discuss with my vet.
I'd desperately love to get pep back down lower on the pred, as I know it's not helping with the pancreatitis, recurring urine infection and muscle/weight loss. My vet has suggested trying Azathioprine, but I would rather not go down the path of another immune suppressing drug. She is so frail and old now I don't think she would handle it or that I want to do that to her. If I'm honest I don't think I could do it again with her at this point. When we did the cyclosporine with her she was only 7 and in much better condition to deal with it and it's nausea and other side effects.
We tried to decrease her pred by 1.25mg when she had the pancreatitis attack and my vet believed this week when I saw her that pep was relapsing again so we had to go back up that drop again. If she really was relapsing it seems something keeps triggering her. Whether the immune system is active due to the urine infection which may be contributing however the infection could have been also a result of the dose increase due to the impa so it's hard to know which order. Either way it isn't helping her signs resolve.

On a Facebook forum I am on, another Aussie has had good success with her impa dog by giving synovan injections. I was always too scared to try as my vet couldn't find any info of their use in impa dogs and we were worried that they may trigger her and she'd have a bad reaction . But we decided we were at the point where risks need to be taken. She had one zydex injection last week then we go back again this week for another at our weekly check up. We are also going to test her poo for worms. We have discussed possibly checking her vitamin b12 too.

I am still not completely sure that she was relapsing. It's summer here and pep always has all her problems in summer. She does not like the heat and possibly there may be an environmental trigger around at this time of year. Whenever we had consecutive hot days in the past she would limp and then would do so for a few days after before coming good again. She just had troubles in the heat and for a few days after. Anyway the 4 days prior to see my vet we had over 43 degree Celsius temps. So that leaves still some doubt in my head that she was definitely relapsing. We don't want to do joint taps on her. But Another thought My vet had is measuring Peps C-Reactive Protein. She said it is typically elevated with poorly controlled IMPA and normal with osteoarthritis. She said there are other factors that can influence C-Reactive Protein so it may give us a false positive also for a separate inflammatory condition. But it could be a means for measuring response to prednisolone rather than joint aspirates. I questioned about the pancreas possibly still being inflamed and if that would cause it to be positive.  She said yes but  together with other tools (ie Spec CPL quantitative specific pancreas lipase measure-)-it may be useful.

My vet sent me a heap of studies to read on digestive enzyme use and how they saw no benefits and some cases where the dogs got bleeding from taking them. She said if we are going to try there is no point unless we use the prescription strength one, used for treating epi. I feel I still would like to try but don't want to use the prescription strength. The place I get peps msm from (Greenpet) and I have also ordered some cranberry powder from sells one called ' Synbiotic 180-S Probiotic & Enzymes' . It's not prescription strength and I discussed with their naturopath what ingredients was in it because pep is very sensitive. She said they have never had any dog get sick from it and didn't seem to think there was anything she should react to in it. I'm going to have to try discuss further with my vet next week.

[Jo CIMDA]

Hi Brooke

Well true to form, Pep is keeping you on your toes.  It must be difficult to assess when you live with such extreme hot weather conditions.  How you tolerate such temperatures, I don't know, and it must be awful for the animals too.

If you use Azathioprine it won't have any real effect for several weeks. I think the question is, does Pep really need immunosuppressive treatment?     Synovan injections will not have any effect on IMPA.  I think they work well for some dogs with arthritis but not all dogs.    Have you considered weaning her off pred and giving a NSAID such as Metacam. This might be an alternative to giving Synovan but again it is just an anti-inflammatory and will not address an immune problem.   

I am not sure if C-Reactive Protein test will tell you anything.  It doesn't identify a specific inflammatory response, so it is not diagnostic.  A positive just suggests that there is inflammation somewhere in the body and this can be a multitude of things.

Your vet seems so good at discussing things with you.  I hope you are able to come up with a plan for Pepper this week.

Jo

[BrookeR]

Hi Jo,
Yes pep is definitely following her usually form of keeping me on my toes.
The hot weather has been terrible. I normally like summer but it's been so humid and hard to do anything even in air conditioning. So I can't imagine how it had been for Pep. Luckily it has cooled down a since those 43 + degree days and we have had constant storms now on and off. Which have still been causing it to be muggy but no where near like it was.

In the past, the two times we have tried nsaids with pep she has ended up even worse & quickly and had to go back on and up with pred. So I don't want to try that as I don't feel she will do wel. I know the Synovan wont help with the impa, but we believe she has normal arthritis at play as well. Especially after seeing the state of her elbow on the X-ray we have been wanting to try the Synovan with her. Hopefully it may help with her normal arthritis and the poor state of her joints. I just was worried it may cause a relapse or trigger a bad reaction from her, that's why I hadn't Tried sooner. She has had 2 injections so far and is okay, with no bad reaction.

I ended up deciding not to do the c-reactive protein test. Instead we did a poo sample and tested her b12 levels. We also tested her urine again which looked fairly good, but my vet said she still wanted to run another course of antibiotics just to make sure. As she didn't believe it was 100% perfect looking at under the microscope. Pep had maintained her same weight from the previous week and her joints looked a bit better. My vet admitted she thought the week prior pep had looked so bad that we would be discussing putting her to sleep very soon But she was greatly impressed by how pep looked this week in comparison to the previous week. The week before she had her head down and didn't want to move anywhere. This week her head was up and she was pacing around. She did however get very anxious on the way there. Normally she is fine going to the vets, but in the car she was panting like crazy, shaking and so anxious looking. Even after we got there she continued to pace around looking anxious. My vet seemed to think maybe it's because our visits were only a week apart and she is getting less tolerant to being poked and prodded. I don't know what was going on. We go back tomorrow so I'll see if she does the same then.

Since I last wrote on her I have started giving pep cranberry powder. She has been fine with it so far. I have also upped her food back to almost normal level and she isn't appearing sick or showing signs of pancreatitis.
The poo sample came back negative to all types of worms including negative to Guardia. I had expected the b12 sample to come back low, but it came back elevated! My vet said this can be caused by liver disease
We didn't do bloods as we had only done those the week prior (her liver levels had looked fine then). I am going back tomorrow and we will be running bloods to check her liver levels again.

I checked the trace vitamins and minerals supplement that I give pep and realised that since she has lost weight and I had also dropped her food back (a while back when she had trouble with her elbow) I hadn't readjusted her dose. So I have been giving her too much for almost 2 months! I've been trying so hard to make sure I get everything right as she is on so much different medication/supplements at different times and being fed 4 times a day. Getting up every night every 2 hrs or so with her has me so exhausted and makes it so hard for my brain to concentrate. I feel terrible that I may have been poisoning her. My vet said that over supplementing could cause her b12 to be up hence why I thought to check the trace vitamins and minerals supplement and therefore saw my terrible mistake. But I have been reading since and read somewhere  that b vitamins are water soluble and will just get wee'd out if you take too many. I'm not sure if this is true or not? It is hard to find info on over supplementing. There is lots of other vitamins and minerals in the supplement, too not just b's....which is concerning. I have stopped giving her the supplement since I realised my horrible mistake.

I have now sadly started to think more that she is in liver failure or has cancer. The night before last she got up in the early hours of the night and was panting and appeared anxious. I didn't feel it was hot. I calmed her quickly and she settled and stopped panting. She did this on one other occasion over the weekend. Her poos had been normal (I have been watching every poo and wee she does)  but last night she did a very runny poo. I have been writing down everything. I.e when she eats, wees, poos, what meds she has and when etc. Just so I can keep an eye on everything. I noticed she is still weeing more frequently than I thought she should be. I emailed my vet with my concerns and said I wanted to drop the pred back again. She wasn't happy about it, I agreed to wait until our appointment tomorrow when we check her bloods. I have, however, stopped the losec as she hasn't been looking sick anymore and out of all the drugs/supplements she is taking this seems the least necessary. That is one less thing her liver has to process. I did also read some sources that said antacids were bad for dogs with liver disease, but my vet said she still uses all the time in dogs with liver disease.

My vet feels Peps joints are of more concern than her liver in terms of her quality of life. She always seems to get annoyed with me when I panic about her liver and want to drop the pred back. I feel bad because I must be the most annoying patient (owner). I throw so much information at her and question everything because I want to understand and make sure I am doing the right thing. I have had bad experience from past vets and that has caused me to question everything and make sure I am comfortable with what we do with pep. I completely trust my vet now. She has been with us since not long after peps impa diagnosis. But I know pep better than anyone else and she doesn't usually follow the 'textbook rules' or the 'normal' when it comes to symptoms and conditions. So even though I trust my vet, sometimes I feel I need to trust my gut and follow what I feel is best for pep because no one knows her better than me. I don't mean to offend my vet and seem like I don't trust her. But it must come off that way sometimes, which I feel terrible for.
Also because I work from home, I am with pep 24/7 and have been since she was 8 weeks old. So I pick up on the tiniest little changes and signs that most people wouldn't notice. Then panic about them and question my vet as to what they could be a sign of or what I think they are.
So I have decided to have email silence with my vet until our appointment and maintain the pred dose as she wanted. I don't want to annoy her anymore. I suppose another day or so to get the bloods results isn't really going to make a difference. If she does have liver disease it is likely too late to change from what I have read. The signs don't really show until the disease is progressed.

[Catherine]

Thank you for updating us - it must have taken you ages to type it all out - but it is good to have detailed information.

Well....there seems to be some good news there and I am glad to hear that Pep, on the whole has improved since the previous week. As she is getting older and maybe some of the medication is taking its toll then that may be why she has a runny poo now and again or an anxious moment. Sometimes older dogs start to wake in the night and wander about or whine.

Some of your post sounds just like me! I have felt awful if I have made a mistake with regard to the medication or treatment of my dog, even though it was minor. But we are only human and coupled with lack of sleep and worry it can happen. Also, the bit about bad experiences in the past with vets, questioning everything your vet says etc. - that's me! I tend to "apologize" to my vet for questioning him at times, but seeing as I have been right and he has been wrong at times, he accepts my questioning him. So hopefully your vet understands too.

[BrookeR]

Thanks so much Catherine for your kinds words. I have been quite down in the dumps the last couple of days, but you have really uplifted my spirits. Much appreciated.
You are right too. I need to keep reminding myself of how old Pep is in the equivalent human years and realise there is going to be up and down days and things that don't make sense. That happens a lot with old people, so it must be the same in dogs. It's hard thinking of her as being so old when we have been together so long and I just feel like she is my mate who has grown with me and hence should age like me. Ive never had an old dog before and didn't realise they could have night restlessness. I had moved away to uni by the time my childhood dog got really old and only then saw her briefly on visits. Actually a lady I was talking to while in my vets waiting room the other day said her old dog was restless at night and had dementia and would get up in the night pacing and wanting food as if it had forgot that it had eaten. So perhaps pep's night restlessness is just old age.

Yes at times I have been right too and my vet has been wrong. She even admits that the times I have been right that she kicks herself a little that I am so in tuned with Pep and perceiving things that are wrong with her. She has commented many times that when I have pushed about something being wrong with her that I am often right, so she always takes my concerns seriously.
I know she understands, but I still feel bad for being 'that' patient/client.

Thanks again Catherine, you have perked me back up ready to take on whatever comes next.

[Catherine]

Thanks for taking the time to say that Brooke and I am glad it helped.

Although some vets think they know it all, good vets appreciate owners who are vigilant. I am sure it makes their lives a bit easier to have an owner rattle off their dog's symptoms, history etc. It also helps the dog for an owner to keep their own records of blood tests, illnesses etc.

But we do need to take a step back now and again and not worry so much - it is just knowing when we can do that.

[Jo CIMDA]

Hi Brooke

You, Catherine and me - and probably many others too - we have all done those things that perhaps we shouldn't have done in attempt to do the right thing for our dogs, and we have all gone with our gut feeling or knowledge and over ridden the vet and have been right.  I challenged a specialist once about Bonnie's treatment of AIHA and she disagreed with me and because she was a Veterinary 'Specialist' I listened to her and ignored my own experience, knowledge and gut feeling, and Bonnie died as a result, so it is important to work together with your vet and listen to your own feelings and assessment of a situation.  You are so in tune with Pep and have always done right by her and thank goodness your vet acknowledges this and you can work well together.

Pep is better than she was a week ago and this is such good news.  She  has been able to improve, indicating that her body is still functioning and repairing when it needs to, and this says a lot.   The liver has to be significantly damaged and the enzymes significantly raised before there is any serious liver damage, and even then, unless there is true liver failure confirmed by clinical signs and blood results,  the liver has the ability to regenerate.  From what you say about her last liver function blood test, she is not at a  level that you should worry about.   

She is an old girl and from what I know about Pep she will not give in easily.  Maybe the Synovan has kicked in and she is in less pain, and maybe it is just making her feel a whole lot better. Old dogs do change in habit and character.  Usually they get more quirky but more adorable as they age  (the same isn't always true of humans!). 

I hope the latest bloods put your mind at rest.

Best wishes
Jo

[BrookeR]

Thanks jo and Catherine. I am and will always be forever grateful for finding this forum years ago now and you both on it. Hands down the most valuable resource in helping Pep on her journey and keeping me sane through it. Whenever I feel lost and need a sounding board I can come here.

Jo, I'm so very sorry to hear what happened to Bonnie. This is why we do all act a little crazy and a little desperate at times because it's a life of someone we love at stake. We are trying to protect them at all costs. Not everyone understands having a dog that is more than a just a pet, but an actual member of your family. The people on this forum do and luckily my vet is one who is very invested in her patients and really does care and go above and beyond to help. So I know she understands why I am like I am. But I must remember to try restrain some when I can.

Pep just did another poo and it was solid and normal formed. So I'm feeling better about that. She had a very restless night and we were up every couple of hours, but it was hot (first hot day we have had in a while). I think the heat caused her to be more restless and annoyingly there has been a neighbours cat visiting our yard. Pep was particularly sniffing around last night every time we went outside, so I'd say it had been there and was bothering her.
She is still much better than she was. Her demeanour is more perky and she is not so distant with better mobility. She is back up to her normal food levels and is having no lip smacking or signs of sickness.
Yes I think I need to accept her habit and character may have just changed some due to her ageing and keep reminding myself that. She's has gotten slower which will happen with age. I need to keep reminding myself that this is going to continue to happen as time passes.

Pep is definitely a fighter. She is so unbelievably resilient. She can get down so low, but she just pulls herself together and claws her way back each time. She loves her family and wants to be here. As long as she keeps fighting, I'll keep fighting for her.

I'll keep you updated how her bloods go. We plan on sending them to the lab rather than doing in house so they are more accurate. That's how we did the last one. This way unfortunately takes a bit longer to come back but it's better to keep consistency.

I will make sure I'm on my best behaviour today and try to keep my questioning within reason. Best just to wait and see what the results say and as long as she is looking better that's really the most important thing.

[Jo CIMDA]

'I think the heat caused her to be more restless and annoyingly there has been a neighbours cat visiting our yard. Pep was particularly sniffing around last night every time we went outside, so I'd say it had been there and was bothering her. '


That made me laugh Brooke,  The day that Pep is not bothered about your neighbour's cat loitering in her back yard, is the day you worry!

Hope all goes well at the vets.

Jo

[BrookeR]

Ha ha yes, you are right. Next door is a bit of an animal sanctuary (on an acre block). Pep loves the neighbours pig, she likes the calf, the sheep & puppies. But the cat....There is no love there at all. Even when she has had bad impa days in the past she can still get herself mobile if that cat is in her yard.

Unfortunately I was right, Peps liver levels were up. They have been higher than this when we have been at really high doses back around first impa time when on immune suppressed levels. But at the low dose we are on they are higher than they have ever been before. We were at this dose only recently when she had the pancreatitis bout and her levels where quite a bit lower. That combined with the increased vitamin b12 is concerning and my vet has told me to back off the pred. She is very concerned though that pep is going to have trouble with her joints once we drop.

To make things worse she slipped badly getting up the night before last on the tiles. She had been waking perfectly fine and came and lay down beside me in the kitchen. I snuck into the bedroom quickly hoping she wouldn't realise I'd gone, so she wouldn't get up. But she realised I'd gone. I didn't see her getting up as id walked around the other side of the bench, but when I heard she'd moved I went to see and she was stuggling to walk as her back leg kept slipping out and she was limping on the front. As if she had done something getting up as she was perfectly fine before she sat down. The following morning her back ankle was huge. I asked my vet if she could hurt herself slipping/twisting on the tiles and if that could cause swelling. She said with pep you can't rule anything out, but generally unless she has pulled a ligament she shouldn't have swelling caused by that. She said if you let me joint tap I can give you an answer. But I'm not going to do that. She walked fine all day on it, but by the time it got to night she would have some trouble when she first got up. It is very puffy and i would think if that was impa she would be in more pain. So we are off to a bad start before we have even dropped the pred.
I am going to order some Dr Buzbys toe grips today to try see if that can help her on the tile floors in our house. I do have runners at certain places for her, Matt's in the living area and I normally lift her whenever I am there. But sometimes I quickly go into another room to grab something hoping she doesn't realise and then she does and tries to get up on her own. Sometimes she is fine but if it's hot or she has done something like this she can struggle.

As for the liver. My vet suggested an ultrasound to try see if there is cancer and to check adrenal glands, for Cushings, pancreas, kidneys etc. It's a lot of money and whenever we have done ultrasounds in the past they have never been conclusive and leave us with more questions. She assured me they wouldn't knock pep out. If they were going to I definitely wouldn't be interested. For now I'm thinking no. I don't know that I want to see cancer and I don't know that it's going to change anything.

My plan is we try drop the pred back if she struggles and becomes too uncomfortable we go up to a dose she can maintain good mobility and be comfortable at. We keep her there until her liver begins to make her uncomfortable and then hopefully Pep tells me when she has had enough. If I know there is no hope I don't want her to suffer.

Pep is allergic to dandelion and so we have never given her milk thistle as I have been scared they seem too closely related. I have been in touch with my human naturopath about milk thistle. She said ' Both Dandelion and St Mary's thistle (aka milk thistle) are both members of the Asteracea family which is a family containing plants with lots of flowering heads. These are often blamed for many an allergic reaction from people who take herbs, however working with the liver can initiate healing reactions, which can often look like allergic reactions...'
She suggested trying to give in drop form. One drop first then increase gradually if she tolerates. I discussed with my vet. She doesn't like herbal things and I have had to email my naturopath again and make sure there will be no alcohol, sweeteners or other additives (still waiting to hear back). She likes the facts and safety that standards and regulations have been followed when made by large drug companies. She wants to try Denmarin. I agreed that I would like to give her this (we currently give her denosyl by them) but I want to initially try with the drops. So we can test how she goes gradually and not have to buy a whole box of it (as it's quite expensive).

Yesterday pep stopped weeing and drinking so much (prior to us dropping pred which I will be doing this morning). I haven't been giving her anymore antacids, I'm stopping that extra stress on her liver. I'm wondering if the cranberry powder is starting to have affect and that has caused her to stop weeing and drinking so much. I would really like to get the urine infection under control as it worry's me  a little that that could be triggering her to keep relapsing. My only other thought is she could have cancer and could that cause her to keep relapsing?

[Catherine]

Is it all the liver levels that are elevated - ALKP, ALT, GGT etc.? Are any other levels elevated? Sometimes you can not just go with blood test results because they can be affected by other things. It may be the beginning of something like liver cancer or something else.

I think, as Peps is an older dog, that, unless anything can be done to help, it will not help having various procedures. It is a difficult choice, as an ultrasound say may show something nasty and then you will feel awful, especially if nothing can be done. Or you still might not get a diagnosis and you will still feel awful thinking that there could be something but it was not able to be determined. You can not win!

Despite Peps's slips, she still sounds as though she is fairly okay so I think your plan sounds good and just go day by day with her. I have never heard of toe grips, it is amazing what they can do to ease dog's problems.

[BrookeR]

I have ordered some of D.R. Buzbys toe grips and am now looking into hock braces for Peps back legs. She has no muscle left and her joints are in terrible condition (most likely missing bone like we saw on her elbow X-ray). My vet doesn't seem to think she could get swelling from slipping/twisting getting up. I don't believe this. I know when I see her this week she is going to insist that it's impa. I don't think her impa is completely in remission but I do feel there is other things going on with her joints as well. We don't have the option to go up in pred anymore so I want to do anything I can to help her joints in other ways. This won't help if it is impa but there is more than just impa happening in her joints. Our whole house is tiles and it's becoming very hard for her. We have Matt's in the living area, and runners near her bed. I try lift her when I'm there but she still gets up sometimes without me.

I feel she hurt her elbow from jumping down off the lounge. The X-ray showed she had bone damage but I believe the jumping irritated it more and caused the swelling. The swelling went up and down and wasn't consistent with increasing pred dose. At some points it went down without increasing the pred. She doesn't jump anymore so her main problem legs  is the back legs slipping out and having no support. So I'm thinking it may be worth trying hock braces.

One of the ones I'm looking at has ceramic powder in them that is supposed to reflect body heat back into the body and promote healing, reduce pain and inflammation. I have seen these before but been worried if they would have any bad effects for dogs that have impa? Here is some detail.

'Back on Track products are therapeutic and made from a fabric which contains polyester thread embedded with a fine ceramic powder. The ceramic powder reflects the dog's own body heat back into the body in the form of FAR infrared waves, which is a thermal heat.
FAR infrared waves have many benefits:
- Increases blood circulation and oxygen supply to tissues.
- Reduces inflammation and swelling in muscles and joints.
- Eases muscle pain and tension.
- Hastens the healing process.
- Warms the muscles prior to exercise, thereby reducing the risk of
  strain and injury'

Pep doesn't like the heat and normally is worse on really hot days with her joints. So that is another reason I am questioning. But that's really hot humid days and this should be more natural body warmth?

Have you heard of anyone use this type of brace with an impa dog? Or have any thoughts on whether it may have negative effects? I'm just not sure about the ' Increases blood circulation and oxygen supply to tissues.'
and whether that would be a good or bad thing for impa?

[BrookeR]

Hi Catherine,
My vet rang me at school pickup time so I didn't get to write down what she said and it was a bit hard to hear. But i sure she said those three were all elevated. We also know b12 is higher than normal from the test the previous week. Which my vet said was a sign of liver disease/cancer. We only ran liver bloods this time and not a complete blood profile. The beginning of liver cancer has been in my mind. I think that's what my vet is thinking.
My vet said some levels can be affected by other things like her urine infection. But for them all to be up and more than before at this pred dose it's not normal for pep and it seems more sinister.

The only other thing that is still in my head I read somewhere when researching msm. That msm had effect on cortisol absorption in the body somehow. I can't find anymore info on this though. If her levels are still high this week we plan on dropping the msm to see if that makes any difference.

Yes that's my exact thoughts about the ultrasound. I don't feel it's going to be beneficial.
Just going to add more questions and worry.

[Catherine]

Is the problem that Peps feet are slipping on the tiles when she gets up or that her legs are too weak to get up?  Do your mats move easily? Would it help (if they are not already) to try and "stick" the mats to the tiles so they do not slip? I am sure there are things you can put under rugs etc. that do not damage the floor underneath. Maybe a rubber mat would "anchor" better?

I know Peps will want to be wherever you are but to save her running (and slipping) when you do not want her to could you not "contain" her somehow - playpen, baby gates, that type of thing?

I have no idea about hock braces although I had a quick look. Personally I would not be in a hurry to get them as they could cause more problems. Hopefully the  toe grips will help.

Perhaps someone else on here has used them.

[BrookeR]

Thanks Catherine. Her feet are slipping on the tiles. But it would also be happening now as they are getting weaker, because she used to be fine. She doesn't slip out, outside on the pavers, or on carpet or Lino. She only slips out on the non textured tiles.

Being a staffy she likes to lay her belly out on the tiles to cool herself. So she will go out of her way to lie somewhere that there is no matt. The matts that there is do not slip, it's just that they are not everywhere and she follows me from room to room putting washing away, going into the kitchen, to the toilet etc.
So maybe trying to contain her is a good idea. But she won't like it and since I don't think she has a long amount of time left. I'd rather her be happy and do what she wants rather than contain her.

You can get braces that don't have the ceramic powder in them and are just for support. So that's another option.