Our Golden Girl

[JenTempest92]

Hi everybody.
My name is Jen and we have an (almost) 2 year old golden retriever named Ally. I know I don't have to explain to everybody here that she is our world, because no doubt you have a waggy tail at home that you feel the same about.
Ally was initially hospitalised 9 and a half weeks ago with a PCV of 9%. It all came as a complete shock because she genuinely didn't seem that poorly, just a bit lethargic and she was drinking more. She had an emergency blood transfusion and the vets initially diagnosed her with primary IMHA (all the other diagnostic tests they did were clear of any concerns).
She was prescribed 60mgs of prednidale alongside 150mgs of Atopica. Her PCV steadily rose to 22% but then started to drop again, so her prednidale dose was increased to 100mgs. About 5 weeks after initial diagnosis we had to make an emergency trip to the vets because she became very poorly, and her PCV was back down to 15% so we introduced mycophenolate. Another week went by and Ally's levels dropped again to 12% so she was given a second transfusion. By this point our vet started to mention something called pure red blood cell aplasia. They assume this is Ally's condition because throughout the entire rollercoaster of a journey she has not shown any signs of regeneration.
We are now almost five weeks on from starting mycophenolate and four weeks from the last transfusion and at the last check up Ally's PCV had started to drop again. I'm worried that we will see this trend continue at our next appointment.
I'm wondering whether anybody out there has a similar diagnosis and can offer some advice on how long it could take Ally to respond to treatment? It's been almost 10 weeks now and she doesn't seem any better (apart from the boosts she's had after each transfusion). My husband thinks she just needs time and I don't want to give up on her, but equally I don't want to keep putting her through such a horrible time if she isn't going to get better.
Any advice or support greatly appreciated and sending love to all the other people/pups out there in our situation!
Jen x

[Catherine]

How much does Ally weigh and how long was she having 60mg of Preds.? Has she been having a gastroprotectant? Below is a good  medication regime.

Jo Tucker should be along soon and will be able to explain things better and help you get Ally well again.



>>>>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!   <<<<

[Jo CIMDA]

Hi Jen

My apologies for not replying sooner, but I have been away.

I am so sorry that Ally has had so many problems with AIHA.  Pure red blood cell aplasia is also known as non-regenerative haemolytic anaemia, and although regenerative AI anaemia is considered to be more prevalent, non-regenerative is also more common in some breeds.   

Non-regenerative AIHA develops because of a genetic predisposition that is unknown until it is then triggered to activate an aberrant immune response, and in Ally's case her own immune system was programmed to target the precursor or immature red blood cells in the bone marrow. 

After immunosuppressive treatment, it can take a while for the bone marrow to kick back in again and start producing new red blood cells.  It can take anything from 5+ days to a few weeks and during this time blood transfusion are given to support the dog whilst waiting for the bone marrow to function properly again.

It is considered that the maximum dose of Prednicare (or prednisolone) is 80mg regardless of the weight and size of the dog.  This is because the side effects of higher a dosage is considered to be detrimental, causing side effects such as blood clots etc. It might be prudent to use an anti-coagulant whilst the dog is on immunosuppressive doses of steroids.

Quote:

Plumb's Veterinary Drug Handbook, 8th Edition: 
Prednisolone Sodium Succinate: 

Goal of therapy is to use as much as is required and as little as possible for as short amount of time as possible.
Dogs: Doses up to 2.2mg/kg/per day.  Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more adverse effects. If further immunosuppression is required, an additional drug is needed.  Many internists believe that prednisolone should not exceed 80mg per day, regardless of dog's weight.

The resistance for Ally's bone marrow to produce new red blood cells (reticulocytes) could 'now' be due to suppression of the bone marrow by the very high dose of prednisolone.  I have known this to happen.  Also, three different immunosuppressive drugs are not usually recommended (if the initial drug doesn't resolve the problem, then two drugs only is preferred).  Now, after all these weeks, there is sufficient immunosuppression by the drugs that Ally is already having, it might be prudent to withdraw the Atopica (cyclosporine), and certainly reduce the preds. It could be the overload of immunosuppressive drugs that are causing the current symptoms and not allowing a rise in the red blood cells (PCV or HCT).  I have known dogs who have been on high doses of prednisolone for too long and the PCV plateaus, and it is not until the dose is significantly reduced that the PCV starts to rise again.   Too much immunosuppression isn't good and is often detrimental to the treatment, and resolution of the disease. 

Now that Ally is on mycophenolate and has been for many weeks, the Atopica could be withdrawn.  Prednisolone MUST NOT be withdrawn suddenly.  Prednisolone MUST be reduced but, if necessary, the dose can be reduced significantly. The reduction depends on how the preds are affecting the dog, in side effects, including a possible suppression of the bone marrow.  Please have a chat with your vet about how to go forward with Ally's treatment.  Certainly, I can see room for improvement with the drug regimen, and with this in mind, you have options, which is so good.

 If your vet is a general practitioner, then it is likely that the treatment of AI disease is not common, this is quite normal, but if he or she is unsure, then a telephone call to a veterinary hospital such as The Royal Veterinary College, at North Mimms, Hertfordshire, or one of the other Veterinary Universities or good referral centres would be worth considering.  If you are not in the UK then there will be other referral centres that you vet can contact.

Your husband is right in that she needs more time, but I believe that her whole drug regimen needs to be looked at and reassessed, possibly reducing preds and withdrawing the Atopica, because so many drugs, especially in high immunosuppressive doses, can be overwhelming and too much for the body to cope with and process.  All the body's organs have to work very hard.   The symptoms of the disease and the side effects of the drugs can become very confusing, and it is difficult at times to know what is causing what!

It is likely that a liver support such as Denamarin could be given, and also a gastroprotectant such as Omeprazole, although gastroprotectants are not prescribed so much these days.  Personally, I think gastroprotectants are worth giving for a few weeks anyway. 

Have a chat with your vet and see how changes can be made to improve Ally.

I have known many, many dogs with non-regenerative AIHA to have recovered with the correct treatment. Remission is achievable, and then you must limit the 'triggers'.  Nothing is assured, but with the right drug protocol it can work.  Ally is a young dog, and I presume otherwise healthy, so this is all positive.

Best wishes
Jo




   

[Jo CIMDA]

Extract from Seminar notes - by Jo Tucker

(AIHA) Non-regenerative Autoimmune Haemolytic Anaemia 
A dog can be anaemic from either blood loss (internal bleeding), or destruction of the red blood cells, or a decrease in their production in the bone marrow. 
There are many reasons why anaemia might develop, eg.  Immune mediated destruction of the red blood cells occurring within the circulation of the blood is known as regenerative immune mediated haemolytic anaemia.  This can be secondary to: tick borne diseases such as Lyme disease, cancer, haemangiosarcoma, parasites, poisoning (zinc, onions etc.), a reaction to drug administration, hyperthermia, systemic disease etc.
or
Primary non-regenerative AIHA (an autoimmune destruction of the immature red blood cells, or the precursor cells, within the bone marrow) where there is no detectible underlying disease.
Primary non-regenerative immune mediated haemolytic anaemia (NRIMHA) may also be termed as acquired Pure Red Cell Aplasia (PRCA).  It is thought that NRIMHA progresses to acquired PRCA and therefore the term PRCA is interchangeable.
The life of a red blood cell is approximately 110-120 days. After this time the old red blood cells naturally leave the body and are replaced by young red blood cells, (reticulocytes).  Reticulocytes are formed in the bone marrow, and when they are mature enough, they migrate to the circulation where they fully mature and then exit the body when their life span is complete.  It's a circle of life – as the old red blood cells die off new ones replace them.  This is a normal daily occurrence.
If this normal process is prevented from happening, as in the case of a dog with non-regenerative AIHA, where the dog's own immune system is producing antibodies which are destroying these young red blood cells or the precursor cells in the bone marrow, eventually the dog will become anaemic.  This is a chronic form of AHIA.
The destruction of the red blood cells in the bone marrow starts some weeks before clinical signs appear and initially, the dog will cope quite well, as their body adjusts to the gradual effects of this form of anaemia.  However, eventually there will come a time when the lack of red blood cells in the circulation shows in various, external clinical signs.
Common, Initial 'Tell-tale' Signs of Chronic Anaemia:
Your dog may have a craving to eat the earth or compost, or chew on concrete or bricks.  Another indicator could be bright, orange coloured faeces and dark coloured urine (this is the blood pigment leaving the body). Your dog may become weak or lethargic, or even collapse for a few minutes through lack of oxygen to the brain, especially when excited. Take a look into your dog's mouth and see if the gums appear pale. If the red blood cell count is extremely low, the tongue and whites of the eyes may have a blue tint to them. Occasionally the dog's gums, skin and possibly whites of the eyes, will look yellow with jaundice. Other signs to consider include loss of appetite, high temperature, inexplicable limping and depression.  Consideration must be given to recent potential trigger factors such as hormone imbalance (recent season/whelping), vaccination, drugs, pesticides, flea treatments etc., also predisposing factors such as breed and age. The family history of your dog is very relevant to any investigation, and can contribute towards achieving a diagnosis of an autoimmune disease. Dogs with a primary autoimmune disease have a genetic predisposition to one or several autoimmune diseases. Autoimmune disease runs in families so it is possible if one dog in a litter, or a relative, develops autoimmune disease the others may follow. 
Non-regenerative haemolytic anaemia is the most common form of primary AIHA but your vet should not assume this diagnosis. As stated previously, a dog can become anaemic for a variety of reasons and these will need to be investigated.  However, it appears some vets don't consider that AIHA can be a primary disease occurring in the bone marrow and very often a grim, incorrect diagnosis of leukaemia is given.  Blood testing and examination of a blood smear is vitally important to a diagnosis of AIHA.  Your vet, however, may want to perform a bone marrow biopsy, but this is an intrusive procedure, especially in a very poorly dog, and is now considered a 'diagnostic overkill'.  A diagnosis of non-regenerative AIHA is often achieved by elimination of other primary or secondary causes of anaemia and, on examination of a blood smear, the absence of immature red blood cells.
Autoimmune disease is often a 'fight against time'.  If the red blood cells are below 12%, a blood transfusion is likely to be necessary to 'buy time' for the treatment to work.  The dog needs to be sustained through this early period of the disease. It is not necessary to have 'typed' donor blood for the first transfusion but subsequent transfusions need to be compatible therefore the recipient's blood should be taken and sent away for blood typing before the first transfusion is given so that the type can be determined should another transfusion be necessary. An alternative to whole blood transfusion is intravenous human immunoglobulin (IVIG).  For more information see this link: http://veterinarymedicine.dvm360.com/just-ask-expert-human-igg-viable-treatment-imha 
Blood transfusions carry risks but they can also save lives. Early diagnosis and treatment may avoid this procedure. 
Once treatment has started, an increase in red blood cells will hopefully be seen in approximately 5 days (the time it takes for the reticulocytes to develop and migrate to the circulation). The level of reticulocytes seen in a normal blood smear is very low. When a dog is recovering from AIHA the levels should be very high and this reflects the level of anaemia.  Correct dosage and duration of treatment is absolutely crucial to a favourable outcome.


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.

[Jo CIMDA]

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.




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. 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 'combination' immunosuppressive drug.  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, or similar, is given to coat and protect the stomach. Another common gastroprotectant used is Omeprazole.
Note: Gastroprotectants must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed
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 addition of a 'combination' therapy immunosuppressive drug is very useful. 
All drugs carry side effects, but they do not carry the same side effects as prednisolone, therefore by using a secondary drug, in combination with prednisolone, the symptoms of iatrogenic Cushing's syndrome can be minimised.  Some 'combination' immunosuppressant drugs as Azathioprine or cyclosporine, take at least 10 days to take effect, so 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.  The advantage of using a secondary drug like Mycophenolate Mofetil alongside prednisolone, is that it starts to take effect within 4 days and this can make all the difference. 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.

[JenTempest92]

Hi Jo and Catherine.
Thank you so much for both your replies to this when things were pretty bad for Ally in September!
A lot has changed since then but I'm pleased to tell you Ally is still here and doing pretty well.
She developed a severe case of pneumonia in December and as a result our vet diagnosed Cushings and started to reduce Ally's medications. They stopped the Atopica and halved the mycophenolate and have been gradually reducing the prednidale ever since. She went from 55mgs to now 10mgs and her PCV was 40.2% last week which is the highest it's ever been. As well as the change in meds she was also treated with long term clavaseptin to protect her from a relapse of the infection which we have just stopped,
My question now is about the Cushing's. Ally has developed really sore lesions all across her back which I think having researched could be calcinosis cutis. We aren't putting anything on the sores at the moment but we are washing them with salt water once a day and keeping her covered up so she doesn't scratch at them. I'm really hoping that they will start to clear up now the preds and clavaseptin have reduced because she must be so uncomfortable but I just wondered how quickly we should see some of the Cushing's symptoms reduce once the preds have stopped all together? Will her skin clear up quite quickly?
Is there anything we can do to treat the sores in the meantime? Our vet is reluctant to prescribe anything given Ally's been on a cocktail of drugs so long so I'm really looking for natural hints and tips that might help!
Thanks in advance
Jen x

[Jo CIMDA]

Hi Jen

Ally has done so well, especially as her bone marrow took a long while to kick back in and also with all the drugs that she had in trying to being the disease into remission.  Great news!

Unfortunately, the very high doses of prednisolone, and over a prolonged period of time will produce some very harsh symptoms of drug induced Cushing's syndrome, and calcinosis cutis is most definitely as a result of the immunosuppressive steroid treatment and is a result of excess calcium.  I do hope the lesions are not too bad.  I have seen some very extreme cases of CC and sometimes the vet will want to remove the crusting lesions by surgery.  Personally, I would avoid this at all costs.    You need to keep Ally as natural as possible and avoid any potential triggers for sparking off another AI disease. It will take some time, maybe months before her skin looks healthy again. The sooner you can reduce the steroids and wean her off the better.  She is still on Mycophenolate, so this will support the reducing protocol that she is on now.

 I do think there are some supplements that you can give that would most certainly help the skin to return to normal function and assist removal of the crustiness.

Essential fatty acids are known, and have proved, to be invaluable to repairing skin because they are anti-inflammatory, and as the name suggests they are essential to healthy skin. EFA's should be given in relatively high doses to achieve the required results. I would start at 500mg of Omega 3 and 500mg of Omega 6 and then increase over a couple of weeks.  Too much oil, too quickly, can cause a loose tummy but gradually introducing it will be OK.   Also, I would add Natural Vitamin E as this encourages new cell growth and it prescribed in so many skin conditions.  It has to be the natural one though, because the synthetic form of vitamin is much less potent and the benefits are very low. 

Extract from my seminar notes 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    (Omega 3 -  e.g., fish oil etc.)
GLA 100mg/10kg    (Omega 6 – e.g., evening primrose oil etc.)
Biotin         2.5mg/dog once a day
•   Natural Vitamin E (400-800iu/12hrs) encourages new cell growth.  (Ref: Clinical Immunology of the Dog and Cat by Michael J Day). 


https://www.petmd.com/dog/care/fatty-acids-pet-skin-and-haircoat-health


I have no personal experience using something called DMSO, but it might be worthy of consideration or at least a discussion with your vet. See these links:

Veterinary Record Case Reports
Companion or Pet Animal
Resolution of iatrogenic calcinosis cutis in a dog through topical application of DMSO


https://bvajournals.onlinelibrary.wiley.com/doi/abs/10.1136/vetreccr-2018-000619


Salt water is a good cleanser, but I have recent experience of looking after someone with inflammation around a port inserted in their chest.  I was using salt water to bathe it, but when I asked the nurse she advised making a paste of bicarbonate of soda and leaving it on the sore area for about 5 minutes and rinsing off.  It really worked wonders, so it might be worth trying a solution of bicarbonate of soda instead of salt to see if that has any added benefits. Just a thought!

The good news is that Alley is in remission from non-regenerative AIHA.  It has been a tough journey, but she is on the mend, which proves that if you can take away the aggressor (the aberrant immune system) her body will fight to get back to normal function and repair.  The eventual withdrawal of immunosuppressive medication will complete the process.  Her body needs time now, to fully recover from the drug induced Cushing's, and that is not only her skin, but muscle weakness etc......

I really do think that supplements will assist, and very likely accelerate the healing of her skin.

Fingers crossed

Jo
 

[JenTempest92]

Hi Jo

Thank you so much for your reply.

Ally is back at the vets tomorrow for a PCV check so we will check with the vet that she is happy for her to have omega 3 and 6 and then get some ordered for her.

All being well we will reduce the preds again tomorrow so I can't imagine it will be too long until it stops all together. She's only on 10mgs now. Since the preds have reduced we have really seen our happy girl again and it's been lovely. Even though she has some side effects of the Cushing's, like muscle weakness and a dip in her back, they don't seem too severe. The only thing I'm worried about is her skin but I know we're doing everything to get it right and it does seem to be better since the preds started to reduce

Thanks again for all your help
Jen x

[Catherine]

Are the sores scabbing? If so are you having trouble with the fur pulling off the scabs before they are ready? If so I found that regularly trimming the area around the scabs with scissors helped stop the hair sticking to the sores.