Hello and introducing myself

[Karen Churchill]

Hi,
One week ago we had a trip to the vet with our Pippa (8 year old working cocker spaniel) for an eye problem only for the vet to discover small red spots on her gums and, after blood tests, the devastating news that she has Immune Mediated Thrombocytopenia (IMT). Her platelets were almost zero (5). After 5 days of Prednisolone her platelets rose to 66. We have more blood test this Friday and the vet has said she is expecting them to be over 100 if things are working. They held off giving vinchristine because her platelets were coming up. We are grateful that the vet noticed this as Pippa was otherwise well. Treatment has been started early and we are praying for a full recovery. Drinking, peeing and having accidents are the norm, with sleepless nights letting her out 4- 5 times a night. She isn't keen on her normal food which is unusual but is begging for anything else on offer.
I was told about this forum by a member on another site and am in the process of ploughing through some of the info and chat.
Thanks for any help I get going forward. This is certainly a very worrying time.

[Catherine]

How much Prednisolone is Pippa on? It sounds like she could be on the correct amount but here is a good medication protocol:

Immunosuppressive Protocols for Oral Prednisolone in the Dog.
Ref: Clinical Immunology of the Dog & Cat by Michael J Day  – 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/q12hrs (every 12 hours)

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h                         10-28 days
0.25mg/kg/q24h                         10-28 days
0.25-0.5mg/kg/ Every other day      at least 21 days
0.25-0.5 mg/kg/ Every third day       at least 21 days

Azathioprine (a cytotoxic drug) can be used in combination with prednisolone at 2mg/kg/24 or 48 hrs and dose gradually reduced, when remission is achieved, over a period of months.
Clinical response to Azathioprine may take up to 6 weeks. (Plumb's Veterinary Drug Handbook)

Don't forget the gastroprotectant! If she is not having one the steroids could be affecting her stomach and appetite.

I expect you have seen these pages but just in case here is a quick link: http://cimda.co.uk/smf/index.php?topic=582.0 and http://cimda.co.uk/smf/index.php?topic=16.0 and there will be plenty of posts if you use the search function on the main page.

[Karen Churchill]

Hiya
Pippa is 13kg and is on 20mg Prednisolone every 12 hours. We have another blood test tomorrow. She seems fine in herself. It is just the peeing in her sleep at night but we understand this is common.

[Karen Churchill]

After some advice - should dogs with IMT, blood platelets at 45 be given fleas and morning treatment?

[Catherine]

Definitely not flea treatment! What is "morning treatment"? Is that what Pippa's platelets were to day? What about her HCT (PCV)?

[Karen Churchill]

Sorry, that should have said worming treatment not morning!
Pippa's platelets have shot up to 191 today.
We have to continue with the same steroid dose for 10 more days as she isn't quite within normal range (200).
We have been told she can have her flea treatment (Easecto) and wormer (millbeworm) by our vet. Is this ok?
Her red blood cells have been fine throughout.

[Catherine]

It is advisable not to worm or give flea treatment to a dog with autoimmune disease and certainly it would be inadvisable whilst she is still recovering. The same applies to vaccinations. I am glad the platelets have gone up (and not the 45).

[Jo CIMDA]

Hello

Great news that Pippa's platelets have increased.  The preds are doing their job and most importantly, her bone marrow is able to function normally.

I absolutely agree with Catherine when she says that a dog with an autoimmune disease shouldn't have any unnecessary medications or treatments.  A dog should only be wormed if it has worms, and only treat for fleas if you see a flea, and then use a natural product. 

When a dog has an autoimmune disease it means that it is genetically predisposed to autoimmunity.  Until the dog shows signs of having an autoimmune disease its immune system is, to all intents and purposes, normal and this genetic status is unknown.  To develop an AI disease it has to be triggered by something and the trigger can be preventative flea/worming treatments, especially the spot-on types,  vaccinations, stress, hormones, drugs etc........  So when a dog is known to have this predisposition then all these things should be avoided, if at all possible, in order to limit the potential triggers.

If a dog has been vaccinated as an adult it is very likely it will be immune to those core diseases for life. Please check out the WSAVA vaccination guidelines.  This is a marvellous resource and its findings are based on current science.  The non-core vaccinations such as leptospirosis should only be given if the dog's lifestyle puts it at risk.  Lepto is very rare and there are over 200 different strains of the disease.  The vaccination only covers 4 serovars and also, because it is a killed virus vaccine, it only last 3-6 months and not the year as we can be led to believe.  Killed virus vaccines are more likely to cause an adverse reaction which can trigger an autoimmune disease.

A dog who has already had an AI disease should not be vaccinated again, and any preventative treatments should not be given for fear of it triggering a relapse or another AI disease.  Only you can decide if these treatments should be given to Pippa but you should do some research so that you are happy with your decision.  Your vet has done a great job in   treating Pippa's IMTP but GP vets are not specialists in autoimmune disease and you need to do all you can to avoid a relapse.  I

Is Pippa having a gastroprotectant such as Omeprazole to protect her stomach from the excess acid that the preds produce?.  If she isn't then ask your vet if he can prescribe it for her.  Don't give Omeprazole within two hours of giving the medication because it will inhibit the absorption of the preds.

The immunosuppressive drug protocol that Catherine posted is the best one that I have come across and it can be tailored to the individual.
Monitor the side effects and reduce sooner if necessary.

Jo 

[Karen Churchill]

Hi Jo
Thanks for the info.
Pippa does have Omperazole but we were told it was ok to give with her food and the steroids all at the same time. Are you saying she should have her steroids and then the Omeprazole 2 hours later? Doesn't the Omeprazole work for 24 hours continuously once it is in the system?
Pippa's trigger is unknown. She hadn't had any recent vaccines, in fact, these are due now. She is prone to getting lots of ticks, she used to get loads before having Easecto. And because tick diseases can cause IMT isn't that a big risk?
Does the fact that she has IMT mean she won't be able to travel to France with us?
Sorry, lots of questions and fears.

[Catherine]

It is not easy, but it is all about trying to reduce the risks. You will probably never know the trigger. When my dog became very ill with AIHA I was advised not to have her vaccinated or wormed again and I never did and she never had a relapse and lived to old age. I never saw any worms so that was fairly easy stopping the worming routine but I did worry about no longer vaccinating her. The things is, autoimmune diseases like AIHA and IMTP can be deadly and once a dog has experienced an autoimmune disease then it can be prone to others and also relapses.

I have no idea whether tick diseases can cause IMTP but if she has been having tick treatment she has got the IMTP anyway....and indeed it could have been the trigger.

Are you talking about taking her to France soon and permanently? If you are just going for a short while it may be best to leave her, if possible with someone who knows how to deal with this disease. Having to take her to another vet and maybe the extra stress of travelling will make things more difficult whilst she is battling this disease.

[Jo CIMDA]

Pippa does have Omperazole but we were told it was ok to give with her food and the steroids all at the same time. Are you saying she should have her steroids and then the Omeprazole 2 hours later? Doesn't the Omeprazole work for 24 hours continuously once it is in the system?


Hi

Yes Omeprazole, once in the system does work continuously but it was always recommended that other drugs should be taken one hour before giving Omeprazole or two hours after omeprazole administration because it can inhibit absorption of the drugs.  This may be because 'In humans and in dogs with normal hepatic function,  the serum half life average is 1 hour but the therapeutic duration is 24-72 hours or more  depending on the dose.'   Plumb's Veterinary Drug Handbook, 8th Edition.


There are lots of different triggers, some known and others are not so identifiable.  Stress  and hormones are huge trigger factors and these are not easily controlled.  Vaccinations and preventative treatments have also caused adverse reactions, so it is a mine field out there.  Once Pippa is in remission you may decide to take the chance and vaccinate her but that will be an informed decision.  You may consider antibody titre testing to see exactly what diseases she is immune to.   When a dog is in remission they are, to all intents and purposes, a 'normal' dog, but if they meet a specific trigger then they may relapse.

It isn't easy, but whatever you decide you have to feel comfortable with your decision.

Jo

[Karen Churchill]

Platelet check today was 238, up from 191 10 days ago. Only a small increase but in the right direction. Another check in 2 weeks time and have to remain on same steroid dose until then. Pippa has lost 1kg so we were concerned about steroid induced diabetes and asked vet to check but all ok.

[Jo CIMDA]

Great news!

If Pippa is still on 20mg of prednsiolone twice a day, it could be that her loss of weight  is because the pred dose dose is too high.

  The recommended staring dose is 1mg/kg/12hours, so for a 13kg dog she should be on roughly 26mg per day for 3-4 weeks.  The majority of dogs put on weight whilst on steroids but some, and in particular sight hounds, lose weight.  It might be that Pippa is one of those dogs in the latter category or it may be muscle loss that has caused a drop in weight.   As she has lost a kilo in weight, if she starts to show unacceptable signs of drug induced Cushing's, then a reduction in preds might be in order.

The increase in platelets means that her bone marrow is working, which is great news.   Below is a some information about side effects of the drugs.

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.
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 corticosteroids 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.
The Importance of Correct Treatment and Dosage
Iatrogenic Cushing's syndrome may also occur if the vet has initially prescribed a dose too high for the size of dog being treated.

For example:  I received an email from the owner of an Irish Setter, with AIHA.  The dog was prescribed 200mg of prednisolone each day. I called the owner, only to hear that the dog had to be put to sleep that day.  I was not surprised. The poor dog was on over twice the highest, recommended dose of prednisolone.  She was 9 years old and had never had a day's illness in her life.  What a terrible shock for the owners and what a lot of unnecessary suffering.  I know what it feels like because I too, have lost a dog due to prescribed overdosing of prednisolone.  The feelings of responsibility are enormous.

In contrast, some dogs are not treated with enough prednisolone.
Example 2:  A greyhound diagnosed with immune mediated thrombocytopenia (IMTP).  Her vet gave her an initial shot of dexamethasone (a steroid which is 6 times stronger in terms of glucocorticoid activity than prednisolone).  Some vets choose to give a shot of 'Dex' as an initial therapy in autoimmune disease, especially if the patient is acutely ill.  Its effects can sometimes be seen within 6 hours and lasts for 36-72 hours.
The vet did really well and a marked improvement in her clinical signs was seen. It is usual, 24 to 48 hours after the shot of Dexamethasone for the treatment to change to an immunosuppressive dose of prednisolone tablets and for the owner to continue treatment in the usual way.  However, the vet only prescribed 5mg of prednisolone a day. The owner said they were very concerned that after a few days of improvement, she seemed to be very poorly again.  The vet couldn't understand why she was not continuing to improve.  He gave her another shot of Dexamethasone and the same improvement was seen.  I suggested to the owner that she either spoke to her vet about putting her dog on an immunosuppressive dose of prednisolone or change her vet.  They saw another vet in the practice, who was more experienced in treating autoimmune disease, and the dog was put on the correct, immunosuppressive dose of prednisolone and the treatment was successful.
These case histories demonstrate how important it is to treat promptly and correctly.
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.

[Karen Churchill]

Jo,

Thank you for your reply.
When Pippa has her next blood platelets check she will have been on 20mg prednisolone twice a day for 32 days so we are hoping that she will be well into the 'normal range' and can start weaning off the steroids.  Her initial weight loss of about 1kg seems to have stabilised and she isn't losing any more weight. The vet said it is likely to be muscle wastage. She tested her for steroid induced diabetes and she was fine. Also, she is still drinking more than normal but nothing like what she was at the start and she isn't having accidents any more or weeing excessively. She is fine in herself.

[Jo CIMDA]

That's all good news.  Fingers crossed.

Jo