Villain Update - Infection

[kezdean24]

Hi,

Following the previous attempt to wean Villain off his pred - we agreed with the vet that we'd stick to the 2x5mg per day for the foreseeable. We also discussed the possibility of Addisons and after a conversation with the lab, got confirmation that the usual test would be affected by his steroids so we would need to go via a different route. We wanted to leave him alone for a while without prodding and pocking but unfortunately he started with the constant shivering yesterday together with vomiting and a little diarrhea so we needed another trip to the vet. His temp was sky high and signs were that of a non specific infection  so we've come home with antibiotics. We took the opportunity to test his electrolytes and they came back as 4 so understand this is in the normal range but still have another (more expensive) one to do to get greater certainty.
Keeping a close eye on him today as he's still off his food and very sleepy - might need to get back down to the vets if he doesn't rally soon.
Anyone on the forum familiar with coping with infections as a side effect of the pred use?
Could also use some info on the alternative tests that can be done for Addisons and what the future could hold if that's what he is diagnosed with?

Thanks in advance as always.

Regards Kerry 

[Penel CIMDA moderator]

Hi Kerry,
Sorry to hear that Villain is poorly again.  It's good that you've been given antibiotics to cover any kind of infection - when Saffy was on high dose preds many years ago, the specialist did the same with her.  Shivering though sounds a bit worrying.  I'm not sure I understand "electrolytes were 4" was there anything more detailed than that?  How is he this evening?
iv'e asked Jo to pop on and have a look too, she might have more ideas than me.

[Jo CIMDA]

Hi Kerry.  I'm sorry for the delay in replying and very sorry you are having trouble with Villian again.  It is not uncommon for a dog to get an infection when it is on preds (or has been on preds for a considerable time).  Preds lower the immune system and the body is unable to fight the infection on its own.  It is, therefore, common for dogs on high doses of preds to be put on a precautionary dose of antibiotics. 

Do you know how high his temperature is?  A dog with Addison's would have a normal or sub normal temperature.  A dog with an infection would have a 'typical' high temperature and a dog with an inflammatory autoimmune deisease would have a very, very high temperature possibly 104+.   Does this help identify what you may be dealing with? 

I can't remember Villian's weight, is he having an immunosuppressive dose of preds.  It is likely he is having a relapse of his AI disease and if I remember right I think you posted a similar message a week or so ago.  Did the vet increase the preds then?  It is common for a dog with immune mediated polyarthritis or steroid responsive meningitis to have a relapse on the first or second  reduction of preds.  Can you let me know his pred hsitory and his weight? 

If a dog has a relapse then the vet has no option but to raise the preds back to an immunosuppressive dose anything less and it will not bring the disease under control and you just prolong the problem.

Sorry I can't help more than this until I have more details.  It does sound as if a relapse is very possible.

Jo

[kezdean24]

Thanks both for replying.

We're 5 days into the anti biotics and Vil's doing ok but certainly not great. Spoke with one of the vets who is familiar with his history yesterday and she said to expect it due to his steroids and that the shivering/trembling should be ignored unless it's really severe (it isn't but it comes and goes continuously through the day and night).

Bit of history as requested Jo.

He's 8.4kg and his original pred dose was 2 x 5mgs once a day. No firm diagnosis but thinking its Steroid responsive meningitis or Addisons. We dropped 1 full tablet a few weeks ago but he appeared to have a bad reaction so we went back to the start. Up to yesterday he carried on with the 2 per day but the vet advised to try another reduction so today he had 7.5 mg and we'll alternative between 10mg and 7.5mg every other day for a week (subject to his reaction).
That's really interesting about his temp Jo. The vet said it was incredibly high (42 which converts to 107) and he didn't know how he was up and about.
He's eating ok now , energy not great (not bed ridden though) but last couple of days it's been his eyes that he's struggling with (we sort one thing and move onto another!). We have drops for his dry eye condition but they've been doing really well without up until recently. He definately has an ulcer in his left eye but his right one is really bothering him today (I thought the vet had checked both again with the dye on Thursday but nothing came up in his right one then). I'll be calling the vet tomorrow when they open for some more drops.
Thanks
Kerry

[Jo CIMDA]

Hi Kerry

If you go into the files you should find a drug protocol by Michael J Day which is the best starting protocol I have come across and if you and your vet follows this then Villian's SRMA should be brought into remission.  The protocol he has been on, and is still on, is not sufficient to bring this disease under control.  It has to be at least 1mg/kg/12hrs prednisolone and this is given for at least 10-28 days. Anything less won't work.  The return of his very high temperature indicates this is what is happening.  The shivvers with SRMA and IMPA is not unusual and I believe it is not only because of the high temperature but also due to the level of pain the dog is in. 

Every steroid you put into a dog should count for something.  If it is not suppressing the immune system then it is next to useless.

Another problem when a dog is not treated with enough steroids is everytime you reduce the preds, the disease will re-emerge and all you are doing is giving him steroids (which will build up) without achieving the goal, so more and more inadequate doses are given until in the end you have such a build up of steroids in the body his adverse reactions to the drug will eventually become a big problem - and he still has the SRMA.  In cases like this is is often necessary to introduce another drug, alongside the preds, to raise the level of immunosuppression because the adverse effects mean that you can't raise the preds any more.

Giving less steroids is not a kindness as in the end you will have given Villian more steroids over a much longer period.  The disease will not be brought under control unless your vet treats him appropriately.  Is there any chance you can take Villian to a specialist or another vet who understands immunosuppressive treatment?

Villians history has illustrated that the treatment is not right.  I hope you can find the courage to take the Michael Day's protocol in to your vet, or alternatively change vets.  Good luck Kerry.

Jo

[Penel CIMDA moderator]

Kerry - here's the link to our info on SRMA.
http://cimda.co.uk/smf/index.php/topic,25.0.html

and this is the link to MJDay drug protocol.
http://cimda.co.uk/smf/index.php/topic,16.0.html

I've copied and pasted the important bit for you
Protocol 2
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
This example is base 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   

Either of the protocols should work but it always depends on how the dog is improving and coping with the drugs.

The dose of azathioprine 2mg/kg/24 or 48 hrs, can be reduced initially by giving a lower dose tablet per day, or gradually reducing from daily dosing to every 2nd day, every 3rd day, every 4th day etc.....  Remember, azathioprine tablets should not be broken or handled without gloves.

[kezdean24]

Thanks again.

There's one of the vets who's really receptive so plan is to book in with him, print the data off and take it in to show him. My gut feel with everything that I've read on the forum was that it wasn't right but you doubt yourself in favour of the 'experts'. Thanks again.


Do you think his declining dry eye is one of the symptoms?

Thanks
Kerry

[Penel CIMDA moderator]

It's certainly could be yes.  Again, something to mention to the vet when you go.  Let us know how you get on.

[kezdean24]

Thanks. Will do. 

[goldiepower]

Hi Kerry

If your vet wants more info about SRMA please ask him to call my vet, I can send you the phone number. I am sure he'll be happy to give his thoughts based on his experience over 12 years he treated Chad.

Hugs to Villain

Chris & the Golden Boys

[kezdean24]

Thanks Chris. I know you mentioned his name a while ago. Would you be good enough to reconfirm name and number to save me searching?

Did your vet follow a similar plan to the high dose recommended here?

Thanks
kerry

[Jo CIMDA]

Hi Kerry

I'm pleased that you are going to take Villian back to the vet with the Michael J Day drug protocol.

I have known SRMA to affect the eyes, but also dry eye can be an AI disesase called keratoconjunctivitis sicca, and just to complicate things dry eye can also be induced by the use of preds!  Are you using Viscotears?  This is a lubricating gel you can get from the chemist and it helps to stop the eyelashes turning into the eye and making it sore.

Has Villian lost head muscle?  This is another reason for the appearance of dry eye as the muscle tone around the eye and eye lid is lost and it no longer holds back the eyelid and stops it from turning inward.

Good luck tomorrow

Jo

[kezdean24]

Hi, good news to report. Had a conversation with the vet this afternoon and he's on board. We're going to do 1 more day of the existing levels so that Villain has had a full week on the antibiotics (just to make sure the infection has gone) and then start the increased dose on Thursday. He also said he wouldn't have recommended a reduction like the other vet did.
We've agreed on an initial 10 days and then a catch up to discuss next steps. Quick question - how do we determine whether 10 days has been sufficient or whether to carry on?
I've also got some tablets to help his stomach.

His dry eye is diagnosed as keratoconjunctivitis sicca and we have all the meds but just haven't needed them since starting the pred (which gives further weight to the vets idea that it all stems from the same AI problem). Its just been since the infection that they took a turn for the worse. Saying that they're looking better today without having put anything in them since this morning.

Thanks for all your help - it gave me just what I need to have todays conversation and hopefully get onto a plan that's going to work once and for all. 

Kerry

[goldiepower]

Thanks Chris. I know you mentioned his name a while ago. Would you be good enough to reconfirm name and number to save me searching?

Hi Kerry, I've sent you the details by PM

Hugs to Villain
Chris & the Golden Boys

[Jo CIMDA]

Hi, good news to report. Had a conversation with the vet this afternoon and he's on board. We're going to do 1 more day of the existing levels so that Villain has had a full week on the antibiotics (just to make sure the infection has gone) and then start the increased dose on Thursday. He also said he wouldn't have recommended a reduction like the other vet did.


*** Brilliant News Kerry.  At last you have a vet to work with.  There is nothing wrong in giving antibiotics alongside the preds.  It is usual practice.
------------

We've agreed on an initial 10 days and then a catch up to discuss next steps. Quick question - how do we determine whether 10 days has been sufficient or whether to carry on?  I've also got some tablets to help his stomach.

*** Good to know that Villian is on a gastroprotectant.  If after the 10 days if Villian is well and coping with any side effects of the drugs then it would be better to keep him on the same dose and re evaluate after week but all the time monitoring the side effetcs if any.  what you don't want to do is to lower the preds before time because he will relapse again and you will be back at square one.  You must make this treatment work.

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His dry eye is diagnosed as keratoconjunctivitis sicca and we have all the meds but just haven't needed them since starting the pred (which gives further weight to the vets idea that it all stems from the same AI problem). Its just been since the infection that they took a turn for the worse. Saying that they're looking better today without having put anything in them since this morning.

*** The problem probably got work because the preds were lowered.  It is likely that as you lower the pred tablets you will have to start back on the topical treatment for his eyes.  I expect Villian to eventually weaned off of all tablets and maybe have to have medication for his eyes.


---------
Thanks for all your help - it gave me just what I need to have todays conversation and hopefully get onto a plan that's going to work once and for all. 

****Most of us have been 'there' and thankfully, in Villian's case, you have got a result - and a vet you can work with - Yeah!  Well done.  I know it is very difficult to pluck up the courage to plead your case with a vet.

Jo