3rd SRMA flare

[Mabel]

Mabel is 20 months. She first had SRMA aged 6 months (diagnosed at RVC)and was treated with 5 months of tapering pred. Then we got her spayed at 13 months and she relapsed within a week. Back on steroids for another 5 months. Just finished and got her vaccinated. 4 weeks later and another relapse. So have just started the steroids at 2mg/kg/day. I have the following questions I'd anyone can help?
1. She is awful on the high doses. Like a totally different dog who is largely absent and miserable. Therefore I'd like to reduce to 1mg/kg after 2 weeks. Then 3/4 weekly tapers. Any suggestions?
2. We don't bother with bloods (vet and I). We see the vet when we need (each time she is poorly) but are now maxed out on insurance so keen to manage without diagnostics. Plus the signs are really clear. Is this ok?
3. Both times on steroids she has been really sick on omeprazole (and when not on steroids after a small incident with ibuprofen - it is a known side effect but therefore I cannot give her gastric protection. Any suggestions? (I always give the steroids straight After or with food)
4. She has had giardia twice while on steroids and required admission. Any gut protecting recommendations? I worm with panacur regularly.
5. During her vet exam this time she was noted to have a hard lump inside her rectum. NOT related to her anal glands. Vet flummoxed. Anyone here ever had anything similar?
6. At what point do you consider low dose steroids for life to protect against relapse? It's the horror of the high dose and her total personality change and misery that I hate.

Thank you all for any help. I'm devastated at this latest flare and just want my baby well.

[Jo CIMDA]

Hi

Poor Mabel, and you too.  It is so stressful looking after a dog with an inflammatory AI disease, and dealing with relapses.  Clearly, the spaying and vaccination have triggered these relapses.  At least she will not have anymore seasons, which can also be a trigger for AI disease.  Also, anything like vaccinations, and any spot on, worming, or other treatments etc., that are just preventative and unnecessary should not be given.  Limit any potential triggers as best you can - I know that isn't always easy but it is necessary.


1. She is awful on the high doses. Like a totally different dog who is largely absent and miserable. Therefore I'd like to reduce to 1mg/kg after 2 weeks. Then 3/4 weekly tapers. Any suggestions?

My personal opinion, reducing the pred dose by half after 2 weeks is risking another relapse, unless of course a second immunosuppressive drug is given alongside the preds.  Using two immunosuppressive drugs is common, especially if the dog has relapsed and the steroids treatment has to be started over again.  Something like, Mycophenolate Mofetil, or leflunomide is really worth consideration. Also, these drugs have a short lead-in time of about 4 days, which is good. If you reduce the preds too soon, then it is likely that the immune system wouldn't have returned to normal function in that time, so as you release the immune system, by reducing the preds, any aberrant immune cells that are programmed, resulting in SRMA, will become active and another relapse will occur.

The best immunosuppressive drug protocol that I have come across is by Prof. M J Day.

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.


2. We don't bother with bloods (vet and I). We see the vet when we need (each time she is poorly) but are now maxed out on insurance so keen to manage without diagnostics. Plus the signs are really clear. Is this ok?

The symptoms of a relapse will be the same as before and usually the vet can treat speculatively.  If the response to the steroids is as you would expect, then the presumptive diagnosis can assumed correct.  The least invasive tests that you do for Mabel the better.

3. Both times on steroids she has been really sick on omeprazole (and when not on steroids after a small incident with ibuprofen - it is a known side effect but therefore I cannot give her gastric protection. Any suggestions? (I always give the steroids straight After or with food)

Ibuprofen is very toxic to dogs and should not be given.
https://www.petpoisonhelpline.com/poison/ibuprofen/

If Omeprazole doesn't agree with Mabel then there are other gastro' drugs that can be given eg., Sucralfate  or Cimetidine, famotidine (Pepcid) etc.  Your vet may also prescribe others if necessary.  Gastroprotectants are not used as much these days when a dog is on high doses of steroids.  Personally, I still think they are worth giving, especially is the dog is struggling with reflux. Avoid giving any gastroprotectant within a couple of hours of giving other drugs as they can inhibit absorption. Certainly, Omeprazole should not be given within one hour of other drugs, or it should be given at least two hours 'before' any other drugs. Yes, always give preds with food.

4. She has had giardia twice while on steroids and required admission. Any gut protecting recommendations? I worm with panacur regularly.

When the immune system is significantly suppressed, infections and parasites etc., can occur. If a dog has worms then you must treat, but I would avoid any preventative treatments in a dog that is genetically predisposed to AI disease because these are potential triggers. I would test first and if there is a particular bacteria or parasite, treat appropriately then, but not on a regular basis, if it is not necessary. 

5. During her vet exam this time she was noted to have a hard lump inside her rectum. NOT related to her anal glands. Vet flummoxed. Anyone here ever had anything similar?

I can't help here, but it is something that the vet can check on every time you visit.  Hopefully it was something, maybe like a benign polyps that may never be a problem. 

6. At what point do you consider low dose steroids for life to protect against relapse? It's the horror of the high dose and her total personality change and misery that I hate.

No low dose of preds will prevent a relapse.  If necessary, it might control a systemic AI disease, but relapses can still occur if a trigger is met and the dose would be raised and then tapered again. A daily dose high enough to prevent an AI disease, would not be tolerated by the dog as the side effects would be too extreme.

The dogs that I have known to have SRMA are very often young, and one or two relapses are not uncommon. The aim of successful treatment is to achieve long term remission.  Just because Mabel has relapsed twice doesn't mean that she can't achieve long term remission.  I have known many young dogs to have relapses, but then, after a while, go on to be stable and never get it again. 

A dog cannot develop an AI disease without a genetic predisposition, which you can do nothing about, and then it is triggered by something which can be identified, as in Mabel's case, or in many cases the trigger is not known.  So  when Mabel's dose is weaned down, and eventually withdrawn, all potential triggers have to be avoided, and this includes vaccination.  I attended a seminar at the RVC about vaccination, and I asked Prof Catchpole: If a dog has had an AI disease, should it be vaccinated again?  His reply was "NO".  He went on to say that always, the benefits and risks have to be weighed up and in this case the risks are too high.

 If you want to know if a dog has immunity to the core diseases then you can have an antibody titre blood test done.  This proves immunity - just vaccinating a dog, assumes immunity.  I am certainly not against vaccination, far from it,  but annual vaccination is not necessary because the core diseases are  live virus vaccines that give many years of immunity, and sometimes for the life of the dog.  Please read the vaccination guidelines:

https://wsava.org/Global-Guidelines/Vaccination-Guidelines/

Mabel is only 20 months, and I honestly feel that there is no reason why she can't achieve long term remission, without maintenance drugs.  See this current therapy to the end, but take the last stages of treatment slower, and gradually wean her off the steroids.  I am very hopeful that this will happen for Mabel.

Best wishes
Jo

[Mabel]

I cannot thank you enough for all this. Just to be clear I know the ibuprofen was toxic - she found a dropped tablet and the poisons line advice was protective treatment with omeprazole - which she was sick with almost daily - but the info on the other meds is helpful if we need it.

Our vet did check with the RVC before vaccination as I had done research and queried whether we should or not (we won't again) but the RVC said they recommended vaccination overall - so that is less helpful of them!

She has definitely improved since starting the steroids again but her bottom/rectal lump is still continuing to be an issue (endless licking/straining for faeces) so am taking her to her be examined again tmw. I think they will want to biopsy (they mentioned this last week) - which I'm also panicking about. We aren't far from RVC so I can get her managed there as I fear this is all going to be a bit complex.

Thank you for your kind words - I cannot tell you how they have reduced my anxiety and given me hope for the future.

Thank you for running such an amazing resource for us all.

[Jo CIMDA]

Hi

I am pleased that you found the info' useful.  Prof Brian Catchpole is at the top of the tree and he has done lots of work research etc., with autoimmune disease.  He is a really good guy and can be trusted.

Personally, I would avoid any invasive investigations unless absolutely necessary, especially while Millie is on immunosuppressive doses of steroids.   High doses of steroids can inhibit wound healing and therefore surgery would not be recommended until the dosage had been significantly reduced.

I hope you have a good meeting with your vet.

Jo

[Catherine]

Omeprazole was not that good for my dog either. Here is a post I did before on the Group:

*****I have just remembered something about the Omeprazole I was given for my dog. The tablets had to be given whole so that the dog could swallow it before the contents opened up. Well, it was quite a large tablet and probably tasted bitter and it was very difficult to get my dog to swallow it without chewing it. She regurgitated her food whilst on the Omeprazole so after a few days I changed to Zitac and things improved immediately. Also you do not have to give the Zitac apart from food AND you can cut them or crush them.

This was a lot easier and I would sprinkle it in her food. Of course you will need to make sure she eats her food. She was on the Zitac quite a while but we never had any problems and it was one less thing to have to remember giving at certain times.*****

Regarding not having blood tests, it depends when Mabel had a full blood test last. Her liver values will elevate on high doses of steroids but the bloods would also alert you to any other problems, maybe regarding the anal lump.

[Mabel]

Thank you for this. Amazingly the lump has gone. Vet astounded. But at least it solves one issue! Mabel responding well to the pred (although weird personality changes again) so we are on our journey and will not rush things!

[Erica]

My whippet, Elsie, had SRMA has as 7 month pup. She responded badly to the high dose steroids and I believe we reduced them too quickly and she relapsed whilst on a low dose. Elsie was put back on the immune suppressing dose and I held my nerve, took each day as it came, keeping her on this dose for 3 weeks. Elsie can't tolerate omeprazole as it gives her diarrhoea and makes her sick. This was difficult in the beginning as the vet thought it was the steroids making her sick.
Elsie has been off the steroids now for 8 months and has been fine. I still worry about her and watch her too intently. She eats well and is very active. I haven't vaccinated her again against the vet's advice. She isn't neutered which is a minor concern.
Good luck.

[Jo CIMDA]

Hi Erica

It is such good news that Elsie has reached remission and has been well for 8 months.  What you have to limit now are the 'triggers' as she will remain in 'normal mode' unless she encounters something that will trigger the immune system into targeting its own body.  The triggers that you need to avoid are unnecessary drugs, regular flea treatment, wormers etc, vaccinations, stress, hormones (which is not easy when a dog is entire) etc.,etc.......

I asked the top Vet at the RVC if a dog that has had an AI disease should ever be vaccinated again, and his reply was No. He continued to say that the risk/benefits have to be considered, and the risks to a genetically predisposed dog is too great.  Do your own homework on the and a good website is WSAVA  vaccination guidelines.

Great news though.

Jo

[Erica]

Thanks Jo, and thanks for your help.
I am glad Elsie is currently okay. I do worm counts, check her for fleas etc. That is quite hard as we have cats which hunt..but I treat them.
You mentioned stress. I haven't had a holiday in 3 years because I have been afraid to leave her but I am worn out ( dad died, mum developed Alzheimer's) and I don't know how I can leave Elsie. We usually have a house sitter who looks after the animals. Elsie is good to leave whilst I am out but she expects me back. I am afraid to go away for fear of her getting stressed. 🙁

[Catherine]

Can you not take Elsie with you on holiday or would she get worried away from home? Perhaps a weekend with family or a friend or someone with a dog Elsie gets on with who can share the responsibility and let you have some time to relax, even if just for a few hours?

[Jo CIMDA]

Hi Erica

I am so sorry about your dad's passing, and your mum's struggle.  Life can be so tough at times.  I understand why you have put your life on hold but it can take its toll, both emotionally and physically. 

You are doing all that you can to avoid 'triggers' but sometimes the trigger just can't be identified, and so many dogs have an AI disease when they are young and do achieve long term remission.  I hope this is true for Elsie.

Fingers crossed Erica.

All the best

Jo