What Antibiotics are safe with impa, Pepper has blood in urine. allergic to cephalexin

[BrookeR]

Hello I have heard that certain antibiotics can trigger impa. We may need to use some, so I wanted to find out what was okay.
Pepper started her cyclosporine yesterday and is off to a bad start. No vomitting or appearance of being sick, after having a half dose in the morning. I gave her famotidine (for the first time) at 4pm and by 5pm she appeared lethargic and a bit unsteady on her feet and hesitant to jump into a chair she would ordinarily have no trouble with. She was also more cautious when laying down. I gave her her entire pred dose at 6.45pm. This was 1 &1/2 (20mg) tablets. She would normally have 1 in the morning and  the other 1/2 at night. But the vet decided it best to seperate the pred and cyclosporine and give cyclosporine  in the morning and pred at night. We are trying to keep her on the pred until the cyclosporine gets in her system enough before reducing the pred in fear that she may relapse otherwise. As we know from a joint tap done over a week ago that the abnormal cells are still there.
She got up this morning and is drinking and peeing more again and has the bloated looking belly again, sway back and head down - depressed. Her breath also smells which it did last time her alp levels were up. I don't know what the bad breath has to do with? I rang our very patient vet and said that something wasn't right. I was concerned her iatrogenic Cushing symptoms had returned and wasn't sure what else was going on.
So..... she has had a blood test done today and checked her liver and pancreas. Liver and pancreas levels are okay. Her alp levels are up in the 2000+'s again. I insisted that she wasn't herself and so our very understanding vet checked her urine and found blood. They have done a urine test & culture and are sending it away to the lab. Hopefully we will have results tomorrow. The suspicion is a urine infection, which we will need to treat with antibiotics. I have heard you need to be careful with impa and antibiotics. To add another spanner in the works pepper is also allergic to cephalexin. So she cannot have anything in the same group as cephalexin. 
She appears not so down and lethargic/ and cautious with jumping and sitting this afternoon. She has spent the day at the vet too so maybe she is just happy to be home. But she also hasn't had the famotidine this afternoon. Yesterday was the first time she has ever had it. I could not find anything much online about any dogs having adverse reactions to it. Pepper is very 'special' and 'individual' in terms of her reactions to different things in the past. So I could not completely rule out that even though no other dogs react to it she might? It's the only thing that has changed since yesterday and she seems more upbeat?
Has anyone had any reactions with famotidine or have any ideas?

Also if you could help steer us in the right direction in case we need antibiotics tomorrow that would be great! Thanks so much in advance.
Ps I asked whether she could have kidney failure and our vet said she checked the levels that indicate this and she was fine. I also asked about addisons/ hypocortisolism and she had already checked the levels for this also and she was fine. Plus she also checked her Gall bladder and it was okay too.

[Catherine]

Hello I have heard that certain antibiotics can trigger impa.

--------- Do you mean potentiated sulphonamides in MDR1 dogs? I always avoid these and ask my vet if he prescribes anything new. Have you tried Clavaseptin? I found that very good with my AIHA dog.

It's the only thing that has changed since yesterday and she seems more upbeat?

---------- You also started the Cyclosporine and gave her her Preds all at once instead of morning and night.....

Her breath also smells

----------- It might be the steroids - see this thread: http://cimda.co.uk/smf/index.php?topic=612.0

[Jo CIMDA]

Hi

Yes, potentiated sulphonamide antibiotics are known to have caused an immune mediated reaction in some dogs so I would stay away from those.

The antibiotic, Marbocyl (Marbofloxacin) is often used for urine infections so that may be OK.    This drug come under the heading of Fluroquinolone antibiotics. 

Urine infections are not unusual when a dog is on steroids.  It may be that Pepper needs more than the usual 7-10 days worth because some urine infections are very stubborn.

GI effects are listed as a possible adverse reaction with Famotidine.

I hope you can get it sorted tomorrow.

Jo

[BrookeR]

It had been mentioned to me  that there were certain antibiotics you were not supposed to use again in dogs such as pepper (impa- immune mediated disease). Pencillin based antibiotics? My vet was also straight away concerned about using the right one. I had heard mention of this prior, but haven't needed to worry about looking into it until now. So I dont know anything more than a concern and wanting to find out more, to make an educated decision. No Pepper has not had clavaseptin before.

Yes I gave her the cyclosporine. A different drug that she has briefly tried in the past (3-4yrs ago) while she was also having pred at the same time (prescribed for her allergies), she never had a reaction like this then.
I gave her the cyclosporine  at 7:30am in the morning. She was fine all day, no signs at all that she was different, and then at 4 she had flamotidine. She laid down and watched tv for an hour with me until 5 and then when she got up (prior to having the having any steroids that day) this is when I noticed the symptoms.  I did not give her the 1 & 1/2 pred until 7.30pm later that night. She was still off yesterday morning when she got up, but not in terms of the unsteady/cautious sitting and jumping. Just depressed and sluggish. I again gave her the cyclosporine at 7.30am and took her to the vet at 11am with my concerns about her liver/kidneys etc having trouble processing the drugs? Because she was very sluggish and down for a few days after her joint tap sedation also. When I picked her up at 5 she was much more upbeat. I did not give her the famotidine again. She did a soft serve consistency poo at around 6.30pm which she strained with for a bit . She also did this after her joint tap sedation when I brought her home. I gave her the 1 1/2 pred at 7.30pm. I have got up this morning and she is still looking better. No unsteady feet or cautious, slow behaviour.
I do understand it could still be a reaction to the cyclosporine and pred. But considering the circumstances I have detailed above and that she has tried both drugs together before, but has never has flamotidine.  I thought it was worth mentioning to see if anyone else has had a similar situation. The vet thought if she had a reaction to cyclosporine she would have been showing signs of being ill more likely within 30min -1hr of taking it. She also thought initially that it was the pred (or combination of drugs) making her sick. Until we pieced out the time line and realised that she hadn't had her dose of pred when she started the symptoms. She hasn't heard of a reaction like that to famotidine, but decided to not give it to her again and see if the symptoms change.
I will have a read of your suggested post about the bad breath and steroids.

[BrookeR]

Thanks Jo. I will have a look into Marbocyl. I am normally concerned about giving her antibiotics due to her allergy to cephalexin. They have told me to mention it whenever she goes to any vets before they give her anything that may be related to it. Her reaction has only been puffing up with bad hives all over her so far & she pants a bit and stresses (probably because I stress). But they warned me that the more times she came in contact with it her allergic reaction could elevate and become worse. She has been exposed to it 4 times over a period of years before I realised what was causing it. As the reaction takes 5 days to show up. But when I heard that there was some antibiotics  that could be a concern in terms of her impa I got more worried and wanted to make sure we choose the right one. I feel bad now having to give her yet another drug. The cyclo and pred and now an antibiotic and I don't know what we are going to do now about a gastroprotectant? She will be having a real drug cocktail .

[Jo CIMDA]

I don't know what we are going to do now about a gastroprotectant?

Can you use Ranitidine?  I think this is a good gastroprotectant.

Jo

[BrookeR]

Peppers results from the urine test have came back and it's not good. There has been no growth, so it's not looking to be a urine infection that caused the blood in her wee. She had an increase in protein loss through her urine. I think the vet said around 0.5 was okay and she was 2.8.
She has referred we go down to see a specialist in Sydney asap and have an ultrasound of her abdomen done by the best equipment and specialists available here. I have her booked in for Wednesday afternoon, this was the soonest we could get in.
She has not had another very bad reaction since we discontinued the famotidine. In terms of the being unsteady on her feet etc as per my previous explanation. She is still very down and is looking pot bellied and slouched in her back, plus the increased drinking. She had a similar reaction after she was sedated for the joint tap with pamlin (diazepam). My vet rightly so thinks there is something sinister going on   although she was hesitant to alarm me with too many bad thoughts on exactly what this could be. Even though I had all ready been doing research and am beside myself with worry of what could be.
But putting aside the permanent very bad thoughts, I have just been trying to read about nephrotoxicity. As peppers worst reactions were initially after she had had different drugs (famotidine & diazepam) and with time after the drug was withdrawn ( a day or so) her symptoms improved. I know if she has some sort of permanent kidney damage/and took these extra drugs she would also display signs of her kidneys failing. But I'm wondering about if it could be temporary kidney failure due to the interaction of these drugs? I have found there to be reports of nephrotoxic interactions between cyclosporine and famotidine. I haven't had a chance to look into pamlin (diazepam) and prednisone interactions in terms of nephrotoxicity. I know I may not have the correct terminology but I hope someone can understand what I am trying to get at and see if anyone has any thoughts.

Pepper only had a urine test 3 weeks ago and there was no sign of blood then but they would not have ran the protein test. Our vet prior to the urine results coming back said the blood test levels that relate to the kidneys showed her kidneys to be okay? As I was concerned this may have been the problem and specifically asked to check her for kidney problems. Any thoughts anyone has would be great. Sorry for the rambling I'm so so worried. I'm also extremely concerned how she is going to go being sedated again considering how slow her recover was last time

[Catherine]

Has she still got blood in her urine? When did you first notice it? I presume it is nothing to do with coming "on heat"?
How long ago did she have a complete haematology and biochemistry blood test?
Maybe not being on a gastroprotectant has caused bleeding.

[BrookeR]

I did not notice the blood in her urine, I noticed she wasn't herself about an hour after having the gastroprotectant (famotidine) for the first time. We were watching tv and when she got up she was a bit unsteady from that point for the remaining evening. She also started the cyclosporine at 7.30am in the morning but had been fine all day until having the famotidine at 4pm. I noticed around 5pm she wasn't right and called the vet first thing the following morning and took her down there and insisted on the testing. The vet noticed the blood in her wee when she did the urine test. I have been watching her pee since then which was last Thursday and have not seen any blood in her wee. Friday afternoon she peed and then 2 minutes later pe d again and then continued to pace around the yard crouching and doing a few drops, getting up again walking a bit and trying again. I only noticed her do this onc and ever since she has been peeing like normal again.
She has been desexed since she was around 1, so not on heat.

If she had bleeding from not being on a gastroprotectant wouldn't it make her sick and not want to eat? She hasn't vomitted at all and is still very hungry and wanting food.

She has been having bloods done monthly since going on the pred but I was very worried about her after the joint tap and took her down and they did bloods because I was worried her liver or something wasn't working properly. So this was only a couple of weeks ago. Because she had taken so long to pick up after the joint tap. She had had some changes in her poo following the sedation and was more sluggish and down. They only did an in house test this time, so it wasn't as detailed and accurate as the previous ones. I am not sure exactly what is involved in a complete haematology and biochemistry if it's different than a normal blood test. I would assume that is what they did? They were testing for any negative impacts the prednisone may have been causing. They said the levels relating to her kidney, liver and pancreas were all  fine?

[Jo CIMDA]

They said the levels relating to her kidney, liver and pancreas were all  fine?


Hi

I would hang on to this and try not to worry too much.  If her kidneys were failing it would be showing up on the blood results.  It seems the most logical reason  for Pepper's upset and clinical signs is the famotidine and now you have stopped it things should return to normal - hope so.

You may feel happier after Wednesday, but stress to them that you don't want her to be given anything unnecessary that might have an adverse reaction.

Jo

[Catherine]

Haematology would check amongst other things for anaemia, white blood cells and platelets. Biochemistry checks amongst other things kidney, liver, cholesterol, glucose and sometimes includes the electrolytes.

Hopefully it was just a blip, but it might be an idea to keep an eye on her red blood cells.

[BrookeR]

Yes you are right and I Have been trying to think positive that her levels have been okay from the blood tests. I have been so insistent on always making sure they check them because of how she has been responding slowly to certain drugs and the impact they seem to have on her compared to the 'normal'. I always thought she must have had a slow metabolism but just don't know now. I'm so worried they have missed something, but I have done everything I possibly can to try avoid this. By researching everything I can and trying to be aware of all possibilities and queriiing any possibilities .

I asked our local vet would they have to knock her out for the ultrasound and she said that she had to be fully sedated for the joint tap but they won't need to do a full sedation for the ultrasound. I have been stressing all night about her not handling the sedation even if it isn't a full one. As she is now on both pred and cyclosporine which would be making her have to work even harder to process things and will affect her recovery. Our vet said they have to lie on their back for a long period of time and some dogs get annoyed with it. Pepper is the most placid dog I have ever known and I believe she would lay still with some pats and reassurance. She will probably be stressed though as its a 3hr drive and into heavy traffic, and I think if I leave her while she goes in she may panic. Which she wouldn't normally do. I am going to ring our vet in the morning and try and stress my concerns to her to see if she can try convince the specialist to do it without any sedation. I would feel so so much more comfortable knowing she wasn't going to be given anything. Especially when we will be leaving Sydney around 5pm in peak hour for a 3hr plus (in peak hr) drive home where there will be not vets available if she has problems. She will be also due to have  1 1/2 pred tablets at 7pm when we get home. Which I will be very worried about giving her on top of a sedation if we have to do one. She is so sensitive and with all the medication she is on and her immune condition it makes me very very worried about giving her anything that could cause her to react as her options are more limited in terms of treatment due to her current situation.

Our appointment is not until 1.30pm either and I cannot feed her from 12am the night before. They said I can give a small handful of mince in the morning with her cyclosporine. I am a bit concerned also about not being able to feed her properly with the cyclosporine. So far it hasn't made her sick though. She is going to be a nightmare to not be able to feed her all day. I may have to take food with us as she will be starving and exhausted by the time we get home which probably won't be until maybe 8pm?

[BrookeR]

Okay thanks Catherine I will remember to look out for her red blood cell count . I'm pretty certain that they have been doing the biochemistry and haematology tests each time since she was diagnosed and started the pred on a monthly basis . As I have heard mention of the White blood cells etc. that you have listed when they have came back to me each time with the run down of her results.

[Jo CIMDA]

Is there still evidence of blood in Pepper's urine?  If not then have you considered cancelling the appointment on Wednesday and leaving it open to make another if things don't settle down.  It seems a lot of stress for Pepper if it isn't necessary.

Jo

[BrookeR]

I haven't been able to see blood in peppers urine. But the vet said her urine is so dilute it won't be visible to the eye. She said only their machine picked up on it.

I rang our vet yesterday morning with a list of things to ask about the ultrasound and my concerns about the sedation and am feeling a little more comfortable now. I now have a new list of things written down for when we get to the specialist. I'm am going to ask if they will try without sedating her which my vets thinks even though pepper is an excellent patient they will not be willing to. She has told me to tell them and has written in the referral for them to not give her diazepam (Valium), this is what she had for the joint tap. She has also let me know the names of some light sedatives that she thinks may be appropriate for pepper and only have a 2-4hr lifespan in the body. So hopefully when I talk with them I will recognise the drug names they say and be able to feel hopefully at bit at ease.

When I had a better chat with our vet yesterday morning she was talking about getting the specialists to look for some sort of inflammatory condition in her abdomen. Originally just prior to peppers diagnosis with impa she had a bad urine infection where I noticed blood in her urine. Our vet said protein loss can cause dogs to get a urine infection and is wondering if whatever is causing this protein loss could be our trigger for the impa. As we have not found what triggered it yet.
There was no protein test done at the time of her initial urine infection and this is the first protein test she has had done. So we do not know how long this may have been going on for.
She originally had ultrasounds done when they we're trying to diagnose her impa, but they were only done locally. They showed two small inflamed sections in her intestines and a few other small abnormalities, but nothing they thought significant enough at the time to be making her as sick as she was. I have asked our vet to make sure the original ultrasound findings are available to the specialist and have asked they recheck the inflamed intestines and any other small abnormalities while they are there. Our vet believes that we need to get an ultrasound done to see exactly what's going on. This time by the best ultrasound equipment and the most experienced sonographers we have available, so that nothing is missed. If this problem is the trigger of her impa there is no point continuing on with treatment for her impa until we asses the cause.
I am very very concerned at how pepper is going to go today, but I feel that our vet is right about us needing to find the trigger for her impa. I have tried saying this along the way that we needed to look more into her trigger.  If we are going to have a chance at controlling the impa I feel we need to look into this and feel that it is a valid theory. Even though it is very worrying and stressful for Pepper. I would hate to continue down this path of trying to control the impa and never be able to get it under control because there is an underlying issue. Especially now we have missed our chance at controlling it with the pred and we are just starting to try with the cyclosporine.

Hopefully pepper can get through today okay and we can finally get some answers. Hopefully her problems are treatable.
I believe once we get through today it's time to start looking at reducing the pred. Hopefully the cyclosporine will be in her system enough. I feel that she is starting to really struggle with the pred and it's time she needs to start tapering. But she need to get through this ultrasound  first.
Thanks everyone, fingers crossed for today.