Cushings- advice please

[tildesaz]

So our lovely springer ezzy was diagnosed with IMTP 2 and a half years ago. Her second relapse came last August when she dropped her RBC. The vet said he wanted to do a longer wean. She has been on one tablet every third day for a while and was due to come off when Covid hit and he suggested we maintain the dose for now. I've been saying at appts for ages that her skin was getting bad? She's been losing her hair and she was losing weight despite being super hungry. She then cut her paw and a few days later we saw signs of a relapse. She went back on 4 tablets a day, followed by 2 a day and now 1 a day. She's been in for a day of blood tests and a vet I've never spoken to before called last week to say her results were abnormal and she has cushings. We are due to see the usual vet early next week. The aim is to get her off the steroids but what else should I be asking for? She's never been on any tummy protection despite 3 lots of steroids now. She's only 6 and I'm so scared of losing her. I'm also 38 weeks pregnant so super emotional! Any help gratefully received! 

[Jo CIMDA]

Hi and welcome

I am sorry you have had this yo-yo ride with Ezzy and IMTP - unfortunately this is not unusual especially with the first episode.  A slow weaning down at the end of treatment, if the patient doesn't have many Cushing's symptoms is often a very good thing. 

If a relapse happens, then you have to go back to an immunosuppressive dose and follow a good reducing protocol such as Prof Michael J Day's.   If the dose isn't immunosuppressive then the relapse won't be brought under control, and when you lower the preds it is very likely that  the disease process will become active again.   This means more steroids, and an increase in Cushing's symptoms is inevitable. 

Depending on what Ezzy's bloods are showing now, determines the path to take.  If Ezzy's platelets are still not within normal range and she is therefore not in remission, then further immunosuppression is needed.  As she is showing signs of Cushing's both in the bloodwork and in her clinical signs, then it would be prudent to introduce a 'combination' immunosuppressive drug such as Cyclosporine, mycophenolate mofetil, or leflunomide  etc.....  Once the combination drug is active (lead-in time varies from drug to drug) this would allow the preds to be reduced quicker, and significantly reduce the clinical signs of Cushing's.   It is often a balancing act between giving enough immunosuppressive drugs and the side effects.  The good news is, as soon as you start to reduce the preds, the body will start to recover from the effects of Cushing's and her liver enzymes will reduce.  Eventually all these adverse effects will disappear and Ezzy can be a normal dog again.

As you are 38 weeks pregnant, please ask your vet to double check which 'combination' drugs are appropriate, and always use rubber gloves when handling cytotoxic drugs and don't split the tablets.

Long term steroids without giving a gastroprotectant will often cause gastric problems, and sometimes gastric ulcers can develop which may cause regenerative anaemia,  so it is worth talking to your vet about giving a short course of omeprazole.

I understand that you need to get this under control before your baby arrives so find out what stage the IMTP is at (via blood results) and then assess how serious the Cushing's symptoms are,  then you can make a decision whether to just lower the preds (if the IMTP is under control and she is in remission) to reduce the Cushing's symptoms,  or if another drug is needed to control the IMTP.  By introducing another drug you can reduce the preds quicker and still control the IMTP, and reduce the Cushing's.

I do hope your vet will help you to sort this out and get Ezzy's symptoms under control and stable so that you can have your baby with peace of mind, and be confident  that everything is in order.

Jo

[Jo CIMDA]

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.
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.