Steroid Responsive Meningitis ?

[Elaineb1624]

Thanks Polly, so far so good.

[Jo CIMDA]

Hi Elaine

When a dog is on steroids they should have access to water night and day and although this extra drinking will make her want to wee more it will only be for a limited time while she is on the high dose of steroids.  Unfortunately you have found this out the hard way.

SRMA responds well to steroids and the prognosis is excellent as long as the drug regime is correct.

I'm pleased to hear she is improving.

Jo

[Elaineb1624]

Hi,
Our little Whippet has had her follow up visit to the vets, and everything seems to be going in the right direction with the steroids starting to reduce next week, so fingers crossed.

However there are a couple of questions that we're not sure about :

Excercise, any pointers on how we should excercise her, we don't want to do too much too soon.

She came into season as well today, off the wall but could this have been a trigger to her recent illness ?

Many thanks

[Penel CIMDA moderator]

Sometimes hormonal changes can trigger an AI disease but you will never really know. 
It's great to hear that you are due to reduce the medication.  Regarding exercise I'd just do some 10 - 15 minute lead walks, nice and slow. 

[Elaineb1624]

Hi,

Sorry but more advice required please.

Our vet has put our bitch on steroids, 20mg per day, she weighs 10.5kg, and our vet has suggested these are administered every 24 hours, and so far she is doing okay.

However this coming Monday, on our vets advice, she is due to reduce to 15 mg (3 tablets) ONCE daily for 4 weeks, then 10 mg for 4 weeks etc. Would I be right in thinking this doesn't tally with the protocol suggested by Michael J Day, and seems like a too large a reduction ?

Thanks once more.

[Penel CIMDA moderator]

How long has she been on 20mg every 24 hours?
looking back it only looks like 10 days so far, so by then it will be two weeks? is that right?
a reduction to 15mg / 24 hours should be ok.

can you just clarify - 20mg once a day, down to 15mg once a day?

[Jo CIMDA]

Hi

Reducing the dose from 20mg to 15mg a day shouldn't be a problem but, and especially with SRMA, if your little girl is doing well on the initial dose and not showing signs of struggling from the effects steroids,  then it might be prudent for your vet to keep her on this dose for a while longer.  Two weeks may not be long enough to achieve long term remission, regardless of her apparent wellness. 

It is not unusual for dogs with SRMA  to relapse, especially if the treatment is reduced too soon, and if this happens then the treatment has to be increased and started again from scratch. Obviously it is better if this scenario can be avoided.

I hope she is on a gastroprotectant, and although it is a 24 hour prednisolone dose, it can be divided into two and given every 12 hours to avoid stomach irritation and ulceration.

Jo

[Elaineb1624]

Hi,

Many thanks for your responses.

To help clarify further, our girl was originally put onto  40mg every 24 hours, (3/10) or rather 20mg every 12 hours, then after three days, after our vet consulted with Anderson Moore, this was dropped to 20mg  every 24 hours, so she has been on 20mg every 24 hours since 6th October.

Yes she is also on a gastroprotectant (Omeprazole) and has been since the first steroids (Prednicare) were prescribed.

Our vet is happy for her to stay on the higher dose longer, how much longer would you suggest though ? Think we will also split the dosage as suggested.

Thanks again

Elaine.

[Jo CIMDA]

Hi Elaine

I am so glad she is on Omeprazole. 

She has been on steroids for 15 days now, and that is good.  If you can give it to her for at least another week that is even better but clinical signs, caused by adverse effects of the preds, have to be taken into consideration on a daily basis. 

Three weeks is a reasonable time to be on the initial dose but if you can stretch it a little longer then it might be worth it.  There are no guarantees that she will not relapse but keeping her on this dose for a little longer may prevent it from happening.  Unfortunately there is no way of knowing if she will  relapse until you lower the tablets. 

I am so pleased she is doing well.

Jo 

[Elaineb1624]

Hi,
   More support needed please,  firstly  Lois is continuing to do well, however as the winter draws in I am noticing an intolerance to cold with her. She is wearing a light fleece indoors and heating is on. She occasionally shivers. Hence the fleece. Could this be her currant season or side effects of steroids or the SRMA...even a combination of all three!?

Also, as suggested in a previous post we still have Lois on the high dose of steroids and plan to drop down but would Jo mind guiding us how much longer stretching it further than three weeks would be.  We are finding it really scary and would appreciate your help. Would another week be advisable? On this coming monday 27th oct she has been on the 20mg dose three weeks plus three previous days on 40mg until Anderson More suggested the drop to 20mg.
      Thanks in advance.
           Elaine.

[Jo CIMDA]

Hi Elaine

I know how really scary this can be.  I've never forgotten!

I agree 40mg a day is a high dose for a 10kg dog,  although it is within the guidelines for immunosuppressive treatment, so your vet wasn't wrong. 

Starting at 2mg/kg/24hours is usually sufficient and the higher dose is usually only used if the dog is not responding and it is absolutely necessary.  However, it is not unusual to start on 4mg/kg 24 hrs for a few days and then drop to 2mg/kg/24hrs. 

When a dog has been on steroids for three weeks then you have to evaluate the situation every day (ie. clinical signs of the disease, and adverse clinical signs of the drugs) to determine how much longer you can keep the dog on this high dose.   If you see that she is struggling to get to her feet or she is going off her food or panting excessively then it is probably time to lower the drugs.  However, you don't have to push it this far before lowering the drugs especially as she has already been on an immunosuppressive dose for three weeks.  As you know I am not a vet and therefore I can't give you instruction on when and how to lower the drugs but the Michael J day protocol is the best I have come across and it is an excellent guideline. See below.    I would suggest though that three weeks plus three days is a good time to be on an immunosuppressive dose and if Lois' clinical signs are good and you feel the time is right to lower it then that should be fine.  I know you have the seminar notes but I have copied and extract below. 

I would imagine it is the change in the weather that is causing Lois to feel the cold, and letting her wear a fleece is a good idea.  One of my dogs was on steroids for life and he used to get very cold feet.  This might have been because he had a vascular problem but Lois reminded me of how he used to be.     She seems to be doing very well, and you can't ask more at this stage, so you can feel happy and relieved that she has done so well.

Jo




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 up to half. 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
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


Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of 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.

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.

[Elaineb1624]

Hi Jo,
     Thank you so much for all your guidance, it is very much appreciated. Lois has no clinical signs they seemed to go within the first week. She also seems to tolerate the steroids well even on the present high dose. We will reduce to 15mg on monday, i will keep in touch. Hopefully it will be uneventful!
     
Elaine.

[Jo CIMDA]

I am cautiously confident Elaine!  It should be fine.

Jo

[Elaineb1624]

Hi,
   A quick update, we dropped Lois down to 15mg on monday and so far all seems well.
     Paws and everything crossed this remains uneventful!

Elaine.

[Elaineb1624]

Hi Jo,
      I feeling a bit concerned right now and if anyone can help me i would appreciate any input. I have just noticed what i will describe as bruising on Lois's nipples. She is four weeks into her season and seems ok in herself. No temperature or other concerns. The bruising is circular and perfectly sitting round four nipples nearest her tail end. Has anyone had similar happen. Her gums are good colour. I am wondering if its some connection between her season and steroids or whether she should have a blood test. What really scares me is  thrombocytopenia coming into the equation. Please Jo i would appreciate your input on this.
     Thanks in advance. Elaine.