New Member Farley

[Corgilicious]

Thanks so much for your reply. The question I am most struggling with is this: if the addition of another drug (leflunomide, atopica etc) results in vomiting and/or diarrhea is it fair to put the dog through this? There have been so many adverse effects from the prednisone and it has walloped the spark out of Farley already.

[Jo CIMDA]

Hi

All these alternative immunosuppressive drugs have the potential to control the immune system and bring the disease into remission but is is never without some side effects.  Some dogs will cope with the side effects more than others and there is no way of knowing how a dog will react before starting treatment.  Often two or even three drugs are used, sometimes in reduced doses,  in order to give adequate immunosuppression and limit the side effects of each drug.   I think it is worth trying the drug that most suits the condition because it may be that the side effects in Farley will not be as severe as feared.    What do you have to lose?

Some dogs cannot tolerate Atopica and others have no ill effects.  Some breeds, such as sighthounds cannot tolerate high doses of pred that well and yet other breeds can.  Smaller dogs usually tolerate the side effects of preds much better than larger dogs.  It is all about trying the best that is on offer and monitoring the side effects of the drugs and resolution of the disease, and adjusting the dose and duration. 

I do hope you can find a drug/s that best suits Farley.

Jo

[Corgilicious]

Hi everyone,

Farley has tapered to 7.5mg daily and has gained a bit of his old spark. I have a question about a possible complication....iatrogenic cushings.

I noticed some symmetrical hair loss around his genitals and he has gotten rounder and heavier, despite his regular diet. To be honest I was so thrilled to have my dog acting like himself that I want paying close attention.

Can anyone advise on this situation?

As always, thank you all for your support.

Eddy,

Kay

[Jo CIMDA]

Hi Kay

Farley has been on steroids since November and I am not surprised that he is showing signs of iatrogenic Cushing's syndrome. 

If he is doing will in himself then I would ask the clinician at UC Davis if the dose can be dropped to 5mg a day for a few weeks, and then reduced again, because the only way you will see a decline in Cushing's symptoms is to reduce the dose of preds and eventually reduce the dose to a low maintenance, possibly every other day dose, or a low daily dose.

The good news is when the pred dose is significantly reduced to a low maintenance dose most, if not all, of those classic symptoms will fade away and Farley will be back to his old self again.   

This is the next stage of this treatment.  A dog can stay on therapeutic doses of prednisolone indefinitely.  I know it might be a bit scary but it has to be done so that Farley can get back to enjoying his life to the full.  View this as good news and start the reduction.

I will post some info about iatrogenic Cushing's in the hope that it may help.

Jo


WHAT TO EXPECT ONCE IMMUNOSUPPRESSIVE 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. 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.

[Jo CIMDA]

Cont:


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, and other more recently used, immunosuppressive drugs are 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 25%. 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.

[Corgilicious]

THANK YOU! This information is very helpful.

Best,

Kay

[Corgilicious]

Farley has been successfully tapering since last August...almost a year now!

He is down to 5mg every other day. But what I've noticed is that he is now chewing his paws like he did when he Was a puppy and had " allergies" of an unknown source—probably grass according to the dermatologist. .

His allergies made sense when his autoimmune disorder was diagnosed and they went away completely while on the prednisone. Now that we are tapering down the itchiness seems to be back.

Hmmm. Does anyone have ideas on how to treat this without disrupting his tapering schedule for his disorder?

Thanks to all.

[Jo CIMDA]

Hi  Kay

It is good to know that Farely is doing well.

It could be that dropping to a low dose of 5mg EOD has allowed the allergic skin problem to resume, and probably you know that it can be very difficult to pin down the exact cause of an allergy.    In addition to the usual food allergy, fungal causes etc., there is one thing you should check for, and that is a mite called demodex. 

When the immune system is significantly suppressed, it allows opportunistic mites, if present, to become active and this can cause irritation, breaking of the skin and sores.  It often starts around the feet, so it might be prudent to have a check for demodex the next time you are at the vets, because if it is demodex it does need specific treatment.

Assuming there are no mites to treat, Essential fatty acids do have a 'steroid effect'  and are generally good for allergic skin problems.  These are often used in the treatment of AI skin disease for their immunosuppressive properties.  It does take about 2 months to have full effect but it is worth it for sure.

https://veterinary-practice.com/article/essential-fatty-acids-in-veterinary-dermatology-do-they-have-a-place

Jo

[Corgilicious]

Hi Jo,

Thanks so much for your speedy reply. Can you recommend a supplement for the Omega-3? There are so many...

Best,

Kay

[Jo CIMDA]

Hi

There are so many, as you say, but I would just go for one with a good reputation. 

Dorwest herbs do specific dog supplements, but you can give a good human supplement too - and they might be less costly.

I hope the EFA's help

Jo

[Corgilicious]

Thank you 

[Corgilicious]

Hi Everyone,

After 13 months on prednisone Farley is officially in remission according to his visit to UC Davis Veterinary School yesterday.

We had tapered to 5mg every 3rd day and, although there is a slight risk of relapse, she felt that it was more in his favor to stop...finally. Now we need to work on building back some muscle and losing his prednisone belly!

This forum has been a life saver and I thought the good news would give everyone hope. Thank you all for your kind words and support. We couldn't have made this journey without you.

[Jo CIMDA]

Oh that is brilliant news. 

I am so chuffed that this long journey has achieved it's goal and Farley is back to being pred free and well.  UC Davis is an excellent veterinary hospital.

Thank you for letting us know, and thank you also for your kind words.   I am so pleased we could help you and Farely during these stressful times.

Fingers crossed!

Jo

[Corgilicious]

Ok....just a reality check. Is it possible for Farley to display back leg weakness symptoms just days after stopping such a low dose of prednisone (5mg every 3rd day)?

He played pretty well with another dog on Monday, and I am just hoping he's sore, but he sure seems hesitant to get up after laying about for a bit.

Uh oh...

[Jo CIMDA]

Hi

I doubt that stopping such a low dose, given every third day, would cause sudden weakness but sometimes when a dog is weaning down from steroids, as the dose gets low and if true remission hasn't been achieved (there is no way of knowing this),  the inflammation can start up again and so, if this is a relapse of his AI disease,  this might have been coming on slowly for a while without obvious symptoms. 

If true remission has been reached, and then a relapse occurs,  the dog has met a 'trigger' to have started the disease process off again.

Having said that, it may not be a relapse and it might be that he has just over done it with the other dog and has stretched his muscles and ligaments etc., (as if he has been in a gym) and they are aching.

Fingers crossed!

Jo