New member Woody, in need of advice!

[Elaine Graham]

Hello! And thank you for letting us join!

We have two rescue whippets, Woody and Sansa.
We adopted Sansa was from a rescue (the EGLR} and we took Woody in because he was a neglected pet and needed a good home urgently at the time.
Woody is nearly 8 years old, we adopted him at 2.5 years old.

I am trying to keep this brief, but Woody has many health issues – he has corns, also epilepsy (especially triggered by anaesthetic). He is on Trental to thin his blood because he has Idiopathic Vasculitis. (He had been getting scabs on the outer bits of his ears which then dropped off and left a little gap).
Also, he has had a pancarpal arthrodesis on his left wrist because the joint just conked out on him when he was running one day. Our vet suspects connective tissue issues.
So, the recent problem is that over December 2019 – January 2020 lumps developed on all 4 of his legs, all along the tendons, he got a sore throat and he started to struggle a little with his back left leg. He could walk fine but was a little reluctant to sit and get up from a laid position. I got a full blood test done at my local vets and a cell test on one of the lumps. Nothing unusual was found and my vet said, 'give it time'. I was still worried so took Woody to see his Dermatologist. She also ran full blood tests, said his lymph nodes were swollen so tested them. She then called to say the blood tests were all OK, slightly elevated liver but fine. The Lymph nodes were reactive, there were extra cells but no cancer, she thinks it is all immune mediated. Inflammatory cells were mentioned quite a bit. The dermatologist said Woody could be put on steroids. If the lumps clear up then that's a definite indication that it's his immune system. Then the steroids should be decreased until he is on the lowest possible dose. I asked if no steroids are an option. She said 'yes' and if it were her dog this is what she would do to start with.
We did that, but within days we noticed a large puffy looking swelling between his front legs and I contacted the dermatologist and he started on the steroids. The dermatologist has confirmed that she thinks Woody has some sort of Autoimmune disease.

Woody is now on steroids (Prednisolone) He's started on 2 a day, going down to one a day and the ultimate goal is to get him onto as low a dose as possible. He is now much better, all lumps gone, bark back to normal and barely any joint pain. These are the medications he is on now:

Prednisolone 5mg once a day
Trental 400mg half twice a day to help with his Vasculitis

I have joined the Whippet Health Issues FB group and asked questions there, so am starting to understand a little more about the disease, however I have specific questions that I am hoping someone can help me with:
1.   Does anyone know of an Autoimmune specialist in the Yorkshire area of the UK?
2.   What sort of Autoimmune disease could Woody have? The dermatologist said it is a complex area and she is not sure (hence my request about a specialist) I am so glad she has diagnosed this, she has been wonderful and I greatly appreciate her help but think I need someone more specialist now. Am I right?
3.   The dermatologist said I could flea and worm as normal with Bravecto and Milpro but I have NOT done this, I have read that I must not do this, is this right? If so, are there any natural products that are effective. I am worried about ticks, should I start to avoid walks that may be more prone to ticks?
4.   What about his Parvo booster? His booster is due in April, everyone on the Whippet Health Issues FB group have said we need to do a Titer test instead, is this right? Also what if the Titer test shows that he does need to be vaccinated, what then?

Apologies for the length of this! and thank you again for letting me join.

Elaine

[Jo CIMDA]

Hi Elaine and welcome

I am so sorry Woody has these problems.

My personal opinion, going by what you have written, is Woody is very likely to have a multi-systemic autoimmune disease called Systemic Lupus Erythematosus - SLE for short.   I have had a dog with this and it can be controlled with immunosuppressant doses of prednsiolone.  It is always best with SLE to use a combination therapy using steroids and another immunosuppressive drug (there are several to choose from  - azathioprine, cyclosporine, mycophenolate, leflunomide etc.....)

Now that you have had the informed/educated suggestion that it is an autoimmune disease then the most important thing is to start correct  treatment and not worry about  getting a definitive diagnosis.  There is no definitive test for SLE it is diagnosed by a series of major and minor signs:


SLE - Systemic Lupus Erythematosus

SLE is a multi-systemic disease that can affect many parts and systems of the body.  It is categorised into major and minor signs.
Major signs can be:
Shifting lameness (polyarthritis), anaemia and thrombocytopenia (blood abnormalities), skin lesions, kidney nephritis (inflammation)
Minor signs can be:
Inflammation of the heart, lungs & muscles, mouth ulcers, enlarged lymph nodes, gastrointestinal signs (vomiting and diarrhoea), central nervous system may be affected causing: Behavioural changes, seizures, and staggering (ataxia).
Clinical signs can be extremely varied and not all dogs with SLE will show the same symptoms. An antinuclear antibody blood test (ANA) can be useful in diagnosis but a negative result still does not rule out SLE.
The dog will normally demonstrate signs of pain and stiffness in the joints and this may be accompanied with anaemia, skin lesions and one or more of the minor signs.  One would expect the dog to show other clinical signs such as high temperature, enlarged lymph nodes, thrombocytopenia, lethargy, depression, lack of appetite, muscle weakness (myositis) sometimes causing weakness of the throat muscles (megaoesophagus).   Megaoesophagus is a serious complication and if this is present then the quicker correct treatment is started the more chance you have of limiting the effects.  A dog will have difficulty in drinking and eating and this can cause recurring aspirate pneumonia.  The primary autoimmune disease may have been brought under control but the effects of megaoesophagus may not resolve completely.
SLE can affect any body system/s. A definitive diagnosis may not be achieved, but it may be presumed, based on clinical evidence and response to treatment.  Again knowledge of breed predisposition and family history will be beneficial in obtaining a diagnosis.   Dogs can have periods of remission and relapse. 





The most important thing, and this is absolutely crucial to the outcome when treating any inflammatory AI disease, is the correct dosage and duration of treatment.  If the dose is too low it will not be sufficient to significantly suppress the immune system.  If it is too high then the side effects of the drugs can become problematic.  The best immunosuppressive drug protocol I have come across is by Prof Michael J Day.  See below.  this protocol can be confidently used as a guide.

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.


It is very important to give a gastroprotectant with prednisolone.  I shall post some more information after this.

I do hope you can start  Woody on  the correct immunosuppressive dose soon.

Jo

[Jo CIMDA]

Treatment for inflammatory/systemic Autoimmune Disease

Excluding autoimmune diseases where hormone replacement only is required, most of the diseases are treated by significantly suppressing the immune system in order to stop the destruction.  There are only a few exceptions to this.
The drugs most commonly used for the treatment of autoimmune/immune mediated disease are steroids (corticosteroids), such as prednisolone.  These may be used as the sole immunosuppressive agent or used in combination with cytotoxic drugs, such as Azathioprine. Cytotoxic drugs are used in human medicine to prevent the body rejecting transplanted organs. Many vets can be reluctant to use azathioprine with prednisolone as a combination therapy to treat autoimmune disease but there is certainly value in using a combined treatment as azathioprine increases immunosuppression and generally allows the steroids to be weaned down in the shortest possible time whilst maintaining a good level of immunosuppression.  It can make a huge difference to the outcome, and in some cases it makes remission more achievable.

All drugs have the potential to cause side effects and the major concern for treating animals with high doses of steroids and other potent drugs are the unacceptable side effects that may occur.  It is a fine balancing act between bringing the disease into remission and the side effects of the drugs.  All of the above drugs have the potential to cause a degree of liver toxicity but when the drugs are reduced the liver will recover. It has to be stated that without these life- saving drugs, in many cases, the dog would die, but the objective is to use the minimum dose to control the disease, for the minimum duration of time. However, the dose has to be 'immunosuppressive' eg.  Prednisolone 1-2mg/kg/every 12hrs usually starting at 1mg/kg/12hrs (Plumb's Veterinary Drug Handbook). If this dose does not produce the desired effect it can be raised. The action of prednisolone is rapid and at times it works like a 'miracle drug'.  Note: It should be given with food to minimise stomach irritation.

If the dose is too high the side effects may cause other major problems, if it is too low it will not control the disease or achieve remission.  One of the most common accounts are when a dog has been on immunosuppressive doses of prednisolone for too long and they start to display overwhelming signs of iatrogenic Cushing's syndrome (see below) and very often the clinical progress they have made in combating the disease has reached a plateau and the dog now appears to be weak, off their food and quite depressed. Prolonged, high doses of prednisolone can also cause bone marrow depression and the red blood cell count can decrease. These clinical signs can cause confusion for the vet and owner, and a relapse of the autoimmune disease is often suspected. It is not unusual for the steroids to be increased when in fact they should be decreased. 

Azathioprine is usually tolerated well, but as with all drugs individual dogs can be affected in different ways.  Side effects can include reduced bone marrow production, but this is rarely a problem unless the dog is kept on this drug for a long time. In contrast to prednisolone which has a rapid effect on the immune system, azathioprine takes at least 10 days to have some effect and approximately 4-6 weeks to reach its full potential. 

Note:  Azathioprine and all other cytotoxic drugs should be handled with extreme care. Cytotoxic drugs should not be handled by pregnant women.  Rubber gloves should be worn and the tablets should never be split or broken.

Atopica  (cyclosporine) is licensed for treatment of atopic dermatitis in the dog but it's increasingly being used as an immunosuppressant in 'combination' treatment with prednisolone and azathioprine for systemic autoimmune disease, despite the drug sheet stating   'It is not recommended to use other immunosuppressive agents concomitantly'.  I have known many dogs on this triple combination treatment that have eventually become overwhelmed by the side effects of the drugs and the outcome has been poor.  It may be worth, initially, trying a more simple approach to treatment, using immunosuppressive doses of prednisolone, before embarking on a 'prescription overkill' that may prove to be a difficult, and an unnecessarily heavy drug regime for the dog.   The link below is an excellent resource:
https://www.dvm360.com/view/immunosuppressive-drugs-beyond-glucocorticoids-proceedings

It must be accepted that sometimes these 'heavy' drugs have to be used, especially if the dog is not responding to treatment; and sometimes an additional drug can make all the difference to the recovery of the dog. In these cases the side effects have to be accepted as a 'trade off', in fact the dog may tolerate it very well.  However, there may be no need to prescribe combination drugs when there is a good chance that using immunosuppressive doses of steroids, and following the correct drug regime, may be all that is required to bring the disease under control.  The severity of the disease has to be taken into consideration when deciding on which combination drug regime to use, but more isn't necessarily best, and introducing one combination drug at a time would limit the side effects for the dog.
In addition to drugs used to suppress the immune system, preventative measures such as administering antibiotics to prevent infection, gastroprotectants to avoid stomach ulcers, and low dose Aspirin to minimise the risk of thromboembolism and DIC (disseminated intravascular coagulation) may be given. 

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]

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.


  NOTE:  The above is quite typical of drug induced Cushing's but some breeds, such as sighthounds, the effect of prednisolone can be quite different, and the most significant is loss of weight.  I have known lots of sighthounds, and in particular Whippets, to have this response to immunosuppressive doses of steroids, but as long as the drugs are having the desired effect on the immune system and a good protocol is followed they do recover as the dosage is lowered. 


Jo

[Elaine Graham]

Dear Jo

Thank you so much for this, it will take me a while to fully digest all this information but on first reading I can totally see what you are saying about the SLE – this does seem to fit with quite a few of of our Woody's symptoms. Thank you so much once again, it is amazing, I cannot believe that this place exists.

The thing that has immediately jumped out at me on first glance is the type and quantity of medications he has been given, they don't tie in with what you are advising:
Woody weighs about 14.5kg (he fluctuates!) so I can see that going by the guidance given by Professor Michael DayBSc Woody should have had say 15mg Prednisolone for 10 – 28 days. In fact Woody has had 10 mg for 7 days, now he is on 5mg for 28 days, we are into day 18 of this dosage. After that I am to receive instructions for the next reduced dose. He is NOT on azathioprine, he is also NOT on a gastro protectant. I am worried!! At the moment Woody is very well but I worry for the future if something is wrong.

The dermatologist that has diagnosed this has been wonderful, the symptoms that made his condition more obvious only started at the end of last year and beginning of Jan this year. We had some time of uncertainty at our local vets, but once I took Woody to the dermatologist she got straight onto it, so I don't want to offend her.
How do I tackle this do you think? I asked her today about the gut protection because I read about it on here today, but now I have read about the dosage and the azathioprine I am even more concerned. She is a very nice person, but I find it difficult questioning people's professional judgement and knowledge – how would you suggest that I question this? would you do? Should I send her everything you have sent me? Or will it get her back up if I do this?

Thank you once again Elaine
PS I raise money for sighthound rescue, do you have any dog charities that you support that need donations? It isn't much but I just do what I can.

[Jo CIMDA]

Hi Elaine

Questioning your vet and even worse a specialist is very difficult, but when you have a dog with an autoimmune disease then your vet must work together with you for Woody's sake, even if it means ultimately changing your vet.

It is not uncommon, if the vet doesn't have experience of inflammatory AI disease,  for an autoimmune disease to be treated with an anti-inflammatory dose of prednsiolone and for a much shorter duration of time than should be - again treating the condition as more of an allergy and not an autoimmune disease.  The two conditions are immune mediated but have a different disease process.  With an allergic response, the immune system is calmed with an anti inflammatory dose of prednsiolone (0.5-1mg/kg per day) . With an autoimmune disease, the immune system has to be significantly suppressed (almost non-existent) and therefore the dose of prednsiolone has to be immunosuppressive (up to 2.2mg/kg a day - dose is often divided and given twice a day) .

The problem is, if the dog has an AI disease then the lower dose of pred will only suppress the symptoms and not significantly suppress the immune system in order for to to return to normal function and achieve remission.

It isn't easy to challenge your vet but if you feel that Woody's signs are returning as you lower the dose then  this will give you the opportunity to reasonably challenge the drug regimen.

Raising money for sighthound rescue is a really lovely thing to do and it is a worthy charity.  Keep up the good work!!!!

Jo

[Elaine Graham]

Thank you so much Jo!

I have made another appointment to see Woody's dermatologist in a couple of weeks, that will give time to see if Woody's symptoms are coming back. I understand what you are saying re the dose, I think I get the impression she is starting on a low dose to see if it will work, but I need to talk to her about it, as I am worried!
In the meantime do you know of any Auto Immune specialists in the Yorkshire Area (or anywhere really!)? Does such a thing even exist? Although the dermatologist has been wonderful if there is someone that is a real expert in this field then I would ask to be referred to them. I asked my local vet about this on Saturday and she said they do not really exist and basically that I am better sticking to the Dermatologist. What are your thoughts on this?

All the best and thank you very much again! Elaine

[Jo CIMDA]

Hi Elaine

Autoimmune disease specialists come under the 'Internal Medicine Specialist' title.   I don't know whereabouts you are in Yorkshire but North of England is Liverpool Vet School and over the Border into Scotland is Glasgow Vet school.  Both have a very good reputation.

The problem you will have is,  because Woody has been started on prednsiolone, anywhere new would want him to be weaned off and some time left before they would be willing to investigate his condition.  Generally, with a few exceptions, the treatment for an inflammatory AI disease is the same regardless of the specific diagnosis, so in a way now you have started on this journey of using prednsiolone it is about the correct dosage and duration - following a good drug protocol such as the one by Michael J Day's. A definitive diagnosis is not always important if all the clinical signs point to, say, SLE.

If the clinician is convinced it is an AI disease then it is better to start on an immunosuppressive drug regimen than to give half dose of prednsiolone, as this will only temper the clinical signs, but not address the internal destruction of the immune system on Woody's body.

Has Woody improved since he started this treatment?  Has Woody's clinical signs got worse since reducing the dose?   There is no way of testing if the drugs have done their job other than observing the clinical signs.

Your general vet can always call Glasgow or Liverpool for some advice over the telephone.

It would be lovely if you see improvement and this continues, but only time will tell.

Jo
 

[Elaine Graham]

Hi Jo

Thank you very much, yes Woody got dramatically better pretty well the minute he started on the Prednisolone, the lumps on his legs disappeared, his bark became normal and his hip area miraculously  got better as well. Before he started on it he was struggling to sit from standing and to get up from a laid position. Within a day or two of starting the Prednisolone he became like his old self. To look at him now he is like any normal whippet.

However since reducing the dose I think I have noticed a very slight decline in him. He has the steroid at breakfast and by night time he is a bit stiffer, also I think I can see a tiny lump starting on the top of his head and his swallowing and eating is a little louder, like he has a sore throat. He is still dramatically better than he was, but I think I can see a small decline, maybe I am imagining it ..... I will really keep my eye on him.

We are a long way from either Liverpool or Glasgow so I think I will have a long talk with Woody's dermatologist about all this. I am very scared by the fact that the dose he is on may 'only temper the clinical signs, but not address the internal destruction of the immune system on Woody's body' How will we know? Say if he continues to do fairly well on the small dose that he is on, does this mean that he could suddenly go downhill rapidly because he never had the right dose in the first place?

Thank you so much again Elaine

[Jo CIMDA]

Hi Elaine

The fact that Woody responded really well to the initial dose of prednisolone is very good news, and in a way this indicates that, regardless of a definitive diagnosis, immunosuppressive treatment is the way to go.   Likewise, the slight decline since reducing the dose could likely  indicate that the dose may have been too low and not given for long enough. 

With inflammatory AI diseases, if the dose is not high enough or given for long enough, all that is happening is you are putting steroids into Woody's body without the possibility of significantly suppressing his immune system and therefore the underlying immune destruction is not being fully addressed and when you start to reduce the tablets all that happens is the immune response, and clinical signs, increase again - and all the time the side effects of the preds are building up in the body, and this makes it more difficult for the body to cope with if the dose is raised to immunosuppressive. 

Every mg of prednisolone should count for something, but this can only happen if the dosage and duration is right.    Try to chat with your specialist about using the Michael J Day protocol.

The aim is to treat the dog using a good protocol and start to wean down the steroids,  and ultimately go to every other day dosing and even every third day until there are no apparent clinical signs - then you can stop it altogether.  Some dogs will relapse and some won't - there is no way of knowing  but if a good protocol is followed, whilst keeping an eye on the side effects of the drugs, then this is the best chance you have of achieving long term remission.  If the dog relapses after you have weaned it off the drugs, then you have to put the dog back on an immunosuppressive dose again.

I hope you have a good meeting with the specialist.

Jo

[Elaine Graham]

Thank you so much Jo
We have got an appointment next week so I will speak to her in detail, she is very nice so all will be well I'm sure! I've also been thinking that we will take Woody to Liverpool if needs be, if she thinks it is a good idea ..... again this is something I can ask her.
All the best and thank you very much again!

[Jo CIMDA]

Good luck Elaine

Jo

[Elaine Graham]

Thank you Jo!

I had a very good meeting with the Dermatologist.
She is going to contact Liverpool and get their advice on the medications. She was wonderful and said she studied there for a while and really wants to work with them so we feel very positive. We are also willing to go there if needs be.
Before the appointment I sent her your information and she read it. Although she has already done blood tests, because of what you said aboult the SLE she is looking into the SLE route a little more, so she did another blood test on Friday (I think she is sending 2 samples off to be tested).
She has put Woody back onto a higher dose of steroids now (1.0mg/kg/q 12h for at least 10 days, to be reviewed) He has the gastro protection also.

I have read on here that now Woody is on a higher dose of steroids that he needs to avoid busy dog park areas etc. I find this a bit confusing, our local walks are not super busy, but dogs do go on them, do you think we are OK staying on these walks? Or might we be better confining him totally to the garden until the high dose is over with? And how long do we need to be careful for? Or indeed is this a thing for life now? 

All the best Elaine

[Catherine]

That is so good, that your vet is listening to what you say and is also taking advice from others (including Jo). I am sure it gives the dog the best possible chance for a good recovery.

When my dog was ill with Autoimmune Haemoloytic Anaemia I kept her (and my other dogs) to walking in the garden rather than going out into public spaces. As Woody's immune system is being suppressed it will be harder for him to fight off any infections he picks up. Although you may be staying away from other dogs on your walks there are also the infections in the air and on the ground.

It is particularly important when he is on high doses and when he is not so well. I am not experienced with the disease SLE but I should imagine (and Jo will know more) that if it is like some of the other diseases, that once the steroids are reduced to a much lower level, it will be okay to go out walking again to your usual places.

[Elaine Graham]

Thank you very much Catherine, its great to hear how other people have gone about things - we have an orchard area that will be perfect for him, I will have to start thinking of ways to keep them both entertained in there! (we have 2 whippets) They will both sulk like crazy to be denied their walks but it is better that than the alternative!
Thanks once again
Elaine