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Author Topic: auto immune pemphigus  (Read 181 times)

Helen Cooper

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auto immune pemphigus
« on: August 25, 2021, 10:13:12 AM »

Hi, I'm a new member and had a little trouble knowing how to post, but sussed it now. My 9 yr old bearded collie girl Psalm has been diagnosed with Pemphigus an auto immune disease and the vet has put her on steroids.
I am concerned as she has gained 4 kgs in roughly 2 months and is now overweight, also I'm completely new to this and don't know if I'm feeding her the correct diet ..... she's on Eden Country Cuisine which is high protein and high fat and although I've tried to research this AI i'm still at a loss as to how I can help her.
 Sorry this is quite long but I would really appreciate some guidance.

 I was highly recommended to join by Kay Wilkes Tennear.
    Thanks Helen.
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Jo CIMDA

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Re: auto immune pemphigus
« Reply #1 on: August 25, 2021, 11:15:34 AM »

Hi Helen and welcome

I am sorry that Psalm has pemphigus.  Do you know which form of pemphigus she has, and has she improved on the steroids?

The key to treating a dog with an autoimmune disease with steroids is using the correct protocol, and tailoring that protocol to the individual dog, taking into account resolution of the disease and the side effects of the drugs.   Knowing what dose to start with and when to reduce,  is essential to achieving remission and limiting the side effects.   The best protocol that I have come across is by an eminent veterinary professor Michael J Day, who sadly is no longer with us but he has left his legacy for sure.  Most GP vets and, increasingly worrying,  veterinary specialists do not know how to treat a dog with autoimmune disease.  Either they dose too high and the side effects become a problem; they  leave the dog on the higher doses for too long,  or dose too low and the disease never gets into remission but the side effects of the drugs build up.   If it is treated properly then mostly, the end result is good and long term remission can be achieved.  I have copied below, a section from my seminar notes which I hope you will find useful.  If you want the complete seminar notes then please email me at cimda@aslog.co.uk

If Psalm has been on steroids for two months then she should be almost half way through the reducing protocol.   If Psalm isn't on essential fatty acids and Natural vitamin E then she should be because these are know as 'steroid sparing' and Natural Vit E will encourage new cell growth.  She may also need a gastroprotectant, if she isn't already on one.

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.

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.

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.


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Helen Cooper

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Re: auto immune pemphigus
« Reply #2 on: August 29, 2021, 11:12:49 AM »

Hi Jo,
My vet hasn't specified what type of Pemphigus she has but on reading about it I think it's Pemphigus Foliaceous. She started with crusty scabs along her lips upper and lower also on her nose, since being on steroids her lips have cleared but she still has small scabs on her nose plus the pigment on her nose is not smooth. The vet prescribed 6 steroids a day for a month then dropped it down to 4 a day plus antibiotics as the scabs were going inside her nostrils, she now just has small scabs on her nose so has improved and has been on 4 a day for 2 weeks.

The diet she's on is Eden holistic 80/20 with Protein 33%, Crude oils and fats 20%, Omega 6 3.3%, Omega 3 0.3% Vitamin E ( as alpha tocopherol ) 95 mg/kg, I have added this information as you said she needs essential fatty acids and vitamin E, is she getting enough in her diet or should she need supplementing further? also she did suffer with UTI's always on antibiotics until I started giving her organic ACV she hasn't had any since, is it OK to carry on with this.

Psalm has gained weight ( 3-4 kgs ) since being on steroids  and although I knew she would, I am hoping she won't keep gaining weight as she isn't as lively as she was ..... I have reduced her intake of food by 10% and giving her lots of fresh vegetables to fill her up but she's hungry all the time, prior to medication she would occasionally miss meals. Eden is high protein/fats should she be on a high protein diet as I have read conflicting articles on this.?
If she does need extra supplements could you please advise me as to which to get?

Jo I'm sorry for the lengthy reply I just wanted to make sure I've covered everything and thank you so much for your help, it's really appreciated.

   Helen,

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Jo CIMDA

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Re: auto immune pemphigus
« Reply #3 on: August 30, 2021, 10:24:34 PM »

Hi Helen

The food that Psalm is on sounds very good. It is usual for a dog on steroids to put on weight, but she will lose this when she no longer needs to have steroids. It must be horrible to want to eat all the time, but she can't help it.

To get good effect from essential fatty acids the dosage has to be relatively high.  Effectiveness, and to achieve the 'steroid sparing effect'   is said to be dose dependent although the ratio omega 6:3 has not been established.   I would suggest adding evening primrose oil and fish oil to her diet.   Anecdotal:  I knew a beardie once who had PF and the specialist prescribed 3,000 mg a day evening primrose oil and 1,000 mg day fish oil.  If you do increase Psalm's EFA's then I would start at 1000mg EPO and 500mg fish oil and then increase the dose over a few weeks because giving her a higher dose of oil all at once may cause her to have loose stools.

 The dosage of Natural Vitamin E has been established and that is 400iu twice a day (Clinical Immunology of the Dog and Cat by Michael J Day) 

I have copied below some info regarding EFA's taken from my SLO seminar notes.

Jo



  •   Essential Fatty Acids (EFA’s) are given in therapeutic doses, regardless of which primary treatment regime is used.  High doses of EFA’s play an `active’ role in the treatment of skin diseases and should be included in the treatment regimen and in low maintenance doses after remission.  EFA’s are known to be `steroid sparing’ in high doses. This means that they have anti-inflammatory properties which may ultimately, lead to a lower dose of steroids being used and this is especially useful in dogs that remain dependant on steroids. However it is not easy to find a specified dose that is consistently used.  Examples below:

EFA Ratio/Supplements
The ‘therapeutic’ dose of recommended supplements, in the treatment of autoimmune skin disease, often varies from one clinician to another.  Below are some examples with their references.
Quote: “Research is being performed to determine the optimal ratio of omega-6 to omega-3 fatty acids that should be consumed. Previously, it was thought that the ratio should be approximately 15:1. Current recommendations are for ratios of 10:1 to 5:1.” (Omega fatty Acids: sources, Effects, and Therapeutic uses in Dogs, Veterinary Services Department, Drs Foster & Smith, Inc.  Holly Nash, DVM, MS)

Example Therapeutic Dose: Essential Fatty Acids
Quote: “Effect appears to be dose related and optimum doses and the most effective combinations of these oils have not yet been determined. Daily doses of Evening Primrose oil 172mg/kg/day, and Fish oil @ 44mg/kg/day, have been used in dogs over a one year period without ill effects”. (Ref: The Veterinary Formulary by Yolande M Bishop)

•   EFA dose should start at a high level until a response is seen.  This can take up to 12 weeks. EFA’s can cause loose stools. If this occurs, start on a lower dose and build up to the highest dose over a couple of weeks. Avoid using Evening Primrose Oil in dogs with epilepsy.  Always follow manufacturer’s dosing recommendations.

Manual of Skin Diseases of the Dog and Cat by Sue Paterson – Drug therapies for onychodystrophy

Essential Fatty Acid    Dosage differs with individuals   
EPA 400mg/10kg
GLA 100mg/10kg

•   Natural Vitamin E (400-800iu/12hrs) encourages new cell growth.  (Ref: Clinical Immunology of the Dog and Cat by Michael J Day). 
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