Is there always a temp with a relapse of impa?

[BrookeR]

Pepper is still down and I'm really hoping it's just the cyclosporine. But I have a bad feeling that she may be relapsing. As she looks like she did in the couple of weeks prior to getting really sick and being diagnosed with impa. She is down & has her sad face with head hung low (it's not hung low all of the time though). She has a sunken looking back and is more hesitant to move than normal and is a bit off in her back legs when she gets up. She still has periods where she will bark and chase a bird though.
The big difference is that she doesn't have a temp. Her temp was the most prominent thing when she was diagnosed. She is having 10mg of pred every second day & cyclosporine (which isn't in immune suppressant levels in her body). Could that be enough for her to not have a temp? Or is there not always a temp?

[Jo CIMDA]

Hi

Lots of dogs have trouble coping with cyclosporin.  Generally, a dog with an inflammatory autoimmune disease will have a very high temperature, but if it happens when they are receiving treatment,  the disease process is tempered somewhat by the drugs they are having, and it is not as clear cut. 

Anecdotal stories suggest that a relapse when the dog is still on drugs (not immunosuppressive doses) is not as severe as the initial onset. Joint taps or an increase back to immunosuppressive doses of drugs and subsequent improvement, confirms a relapse.

It is so difficult to know if a dog is having a relapse or showing side effects of the drugs.   I have known some vets to wrongly assess the clinical signs and increase the dose of prednisolone, when in fact the dose should be lowered because the clinical signs are due to pred saturation.  It is not an easy situation.

Jo
 

[BrookeR]

Thanks for your info Jo. Pepper was great on Saturday morning when I had given her nothing that morning. No signs at all of limping or being down. But since then the more cyclosporine I have been giving her she has continued to get worse each day. More sleepy and more slow. Initially on Sunday arvo she got better before she was due to have her next dose. Yesterday she didn't perk up as much before her next dose as the afternoon before. But the drug is probably getting more in her system now after 3 weeks of taking it and now having taken the increased 150g for the past 4 days. Last night she almost could not get up in her back end and was her worse yet. She is struggling moving her back end. She appears weakened. When she initially got impa she didn't show joint pain and was just hesitant to move. When she moved it looked like the description 'walking on eggshells'. Which is different from now.
When she relapsed she just began limping badly on mainly her front legs I thought. But she was clearly limping and i do not remember her appearing weakened and having trouble getting up in her back end like this. I have caught her last night limping slightly when she does get up but it's only on the front leg that she has had problems with all along.
I don't know what to do. I read muscle cramps and muscle weakness are less common side effects of cyclosporine. But I don't know if it would be to the extent that she struggles to get up. There isnt much written about rare side effects. Mostly everything just says about the nausea and vomitting. She has been on the pred for so long at higher doses surely the impa cannot be coming back.
I do not feel she is well enough for joint taps again.  I am also so scared that she cannot handle the pred again if she is relapsing. I have decided to not give her the cyclosporine at 6 this morning and take her to the vet when they open at 8. We can always give her the cyclosporine later in the day if the conclusion is made its impa returning.

All I know is Pep was really picking up when we were reducing the pred. Now she has been taking more cyclosporine she has been getting worse. But I know this could also be the impa returning and getting worse, and not the cyclosporine. This is horrible. I don't know what to think. Her liver is not in a state to be having a relapse. If she is relapsing is there an option for her to just maintain her (even though she may be in pain) and wait, giving time for her liver to heal? I do recall the specialist mentioning non steroidal drugs but that the pred needed to be out of their system for 5 days. She said she was personally looking after the dog for the 5 days as it was in so much pain.

I am leaning towards taking her off the cyclosporine and see what happens. If she is relapsing we are in a really bad position no matter what. But the one thing I don't want to do is up the doses when we aren't certain and be treating something that's not there and causing worse damage. We have already done this once I beleive when we left her on the 30mg of pred for a month longer while we waited for advice from the specialist. She was only limping on the one leg and only a few times for  up to 30mins I now honestly believe that was not the polyarthritis and we made a bad choice, putting us where we are now.

[Penel CIMDA moderator]

   it's so difficult isn't it - not knowing what is causing the symptoms you're seeing.

In my personal experience Cyclosporine is a very hard drug for a dog to take successfully.  I've had two dogs on it, neither of which did well on it.  Anecdotal I know, but it wouldn't be my drug of choice for immune suppression again.

[Jo CIMDA]

Hi

I think there is something to be said for stripping back and seeing what clinical signs Pepper is left with.

Some dogs cope better with certain drugs than others - does this mean that when a dog reacts badly to a drug it is, in effect, so toxic to its body that the drug should be stopped?

There is always a 'trade off' but when the negative side effects outweighs the positives then perhaps you have to say this is not the right or appropriate drug for this dog.

IMPA is not a nice disease because it is very painful but it is not a life threatening disease and maybe stripping back the drugs will give a clearer picture and allow you to make a more informed decision. 

When a dog has been treated by a general vet and is then referred to a specialist, usually the specialist will take the dog off of all drugs (weaning off steroids not stopping suddenly) so there is nothing left but the dog and whatever clinical signs it displays.    They do this even though the dog may reach a crisis point because if they don't get a clearer picture it is just a stab in the dark, speculative diagnosis; which isn't satisfactory.

I have known lots of dogs who can't tolerate cyclosporin.

Have a chat with your vet. 

Jo

[BrookeR]

Pepper spent the day at the vet so our vet could monitor her signs and assess what she thought in regards to if she was relapsing and why she was lethargic and having trouble getting up. I had a thought on the way to dropping her off. What if the trouble getting up was just normal arthritis and we are now seeing it because we dropped the pred back to 10mg for every second day on Saturday.? I had been so focused on the cyclosporine as we had been hoping it but didn't think about the decrease in pred. She has had two doses now at the lower pred. We dropped her back at the start of last week for one dose but when the cyclosporine blood level results came back too low our vet said for her next dose to go back to 20mg (thurs) but then Saturday we went back down again to 10mg every second day after talking with the specialist.

Just prior to pepper getting sick and diagnosed with impa she had a urine infection and I had noticed her being ginger in her back legs and having slight trouble getting up. This was around the start of December last year. The vet then assumed it was abdominal pain from the urine infection. After the impa diagnosis we assumed it was the start of the polyarthritis showing. Now I am thinking it was the start of ordinary arthritis showing. She has never had a problem with her joints or arthritis before. Her first joint tap (when diagnosed) had the highest abnormal cell levels in her back (knees). Her most recent joint tap showed the impa appeared gone however there was still increased cells in her back knees. The specialist seemed to think these may have just been normal arthritis.
So after examining pepper and finding no temp, no abnormal swelling or pain in her other joints. I also showed her the video of pepper trying to get up. She believes that it just looked like her having joint pain consistant with normal arthritis in her back end. She is not showing the awkward movement like that of a dog with polyarthritis. Of complete stiffness that gives that stilted gait walk.
So the conclusion we have come to is she now has normal arthritis to add to her list of problems. As you have said before Jo (and in your last reply), we won't know the extent of her problems until we start weaning the meds (in this case the pred) and then we will have a clearer picture. Arthritis appears to be one of such problems.

As for the lethargy and appearing down. This could be adjusting to the cyclosporine but also the new appearance of the arthritis would be making pepper feel bad and less likely to follow me around as much as normal. She doesn't appear to have bad gas like she did. So hopefully the gastro upset from the cyclosporine is settling.

My vet and the specialist have had a good chat and we appear for now to have sorted all our issues out. I had concerns about why we were continuing with the cyclosporine if the polyarthritis was gone. Our specialist said she feels more comfortable to wait until it has been 6 months before safely saying pepper has achieved true remission and we do not want to have to go back up on the pred in case of a relapse, because of her liver. So we need to keep the cyclosporine in her system due to the time it takes to get working to full effect.

My vet also spoke to the specialist about peppers atopic dermatitis and now that we cannot give her allergy vaccines anymore she feels pepper needs something to control them. This is one of the reasons they chose to put pepper on cyclosporine rather than azathioprine, due to her allergies. I don't beleive her allergies are as bad as they used to be, but I think our vet is right for now. Because we only stopped the vaccine just prior to pepper getting sick and she has been on immune suppression since. She had been on the vaccine for a number of years. So we really don't know what will happen. It may come on like the arthritis now we are weaning the pred.
I think it will be better to get her stabilised for a while and hopefully allow her liver and body to recover from the pred before trying anything else.

So the plan is keep her on the 10mg every second day of pred for now. Continue on the 150mg of cyclosporine until after the Easter long weekend. Then we will go up to 200mg cyclosporine  for a week and then do the trough testing again.

The specialist does not want to continue monitoring her alt levels etc so closely. She said we cannot pay so much attention to them. This concerns me of how we know when she has permanent damage. I get the impression she means we have to do what we are doing with the drugs regardless and hope that there won't be permanent damage. They have said the cyclosporine isn't as bad on the liver as the pred and we have the pred at 10mg every second day for now. I guess I just have to trust them for now and continue as they say and hope her liver can handle it. The specialist deals with this situation everyday with other dogs so she should know the limits.

For now I am okay to stick with the cyclosporine for a bit longer. Now that we have worked out the back end trouble is arthritis. But If Pep gets worse and starts showing other bad signs then I will speak up. Her personality has slightly changed. She is a bit more distant sometimes, but I guess this wouldn't be abnormal on such a harsh drug. Now she also has this arthritis pain, she may just be adjusting to the new pain and how she is now limited plus the drugs effects. Pred can cause change in personality which seemed to sort itself out as she adjusted so hopefully its the same now.

Pepper had another session of remedial massage and acupuncture at the vet while she was there. We are going to give her another one on Thursday prior to the Easter long weekend so that hopefully that will get her through to after the public holidays. Then the vet wanted to talk about giving her tramadol. But she said she has a small concern about triggering the impa. I really don't want to do anything to risk triggering the impa. I would prefer to try first to manage the arthritis in other ways if possible. She still is not on a joint supplement and I know that may not work a great deal but definetely worth trying. Then there may be foods that could help with anti inflammatory. I would prefer to look into options first.

Pepper is so hard to asses her symptoms because she has multiple conditions going on. She has the impa, atopic dermatitis, food allergies/intolerances (possible ibd) and now arthritis. The vet has discussed with me that we need to stop looking at her symptoms as a whole and possibly misdiagnosing. We need to look at each symptom individually and work out what condition of peppers that it correlates to and treat individually. But also keep in mind the whole picture in terms of treatment that will not cause problems with one of her other conditions e.g not using something that will trigger the impa

[Catherine]

I can not understand why your vet, not only wants to keep Pepper on the Cyclosporine, but also to increase it! The Cyclosporine could be causing side effects and the elevated liver enzymes.

Please correct me if I have this wrong, but it does not appear as though Pepper has shown much, if any improvement and seems to be having more problems. I agree with Jo that it might be best to aim towards taking Pepper off all the medication (tapering the ones you have to) and to see how Pepper is and restart with a diagnosis.

I know I mentioned this before but did you have Pepper's thyroid tested when her symptoms first began? Skin problems and limping can also be symptoms of Hypothyroidism.

[BrookeR]

The vet seems to think that the symptoms may have been a little misinterpreted. I was only taking into again that we were increasing the cyclosporine and wasn't thinking about that we had also reduced the pred. We have never reduced the pred to this level before since she got impa. Actually that's incorrect. We reduced it way too quickly down to the 1/2 tab (10mg) every second day (within the first month of diagnosis) This is when she had the relapse.

Pepper has never had her thyroid tested. When you previously mentioned hypothyroidism to me it stuck in my mind. I asked my vet about it then and she dismissed it. I had been reading up on it again over the weekend considering if that could be what was going on with the weakness and limping now.  I again mentioned it to the vet (not my usual one) because she wasn't there when we had Peps bloods done and he dismissed it too. ? I have not forgotten it and it is still very much in my thoughts. If after the Easter long weekend she doesn't stabilise I will bring it up again.

The vet has insisted to me that it takes a bit to adjust to meds such as cyclosporine and the sick feeling should pass for her. We need to give her some time on it to assess properly before discounting. They also told me the cyclosporine wasn't as bad in terms of elevated liver enzymes?

I agreed to do as they said by leaving her on the corrent dose of both pred and cyclosporine until next week (after the Easter break). As I don't want to change anything before the long weekend and end up having problems and no help available due to public holidays. If in that time she gets worse I will speak up to them about stopping the cyclosporine.

I just feel that they are right in that I wasn't taking into account what affects the pred reduction could have been bringing out in her at this lowest dose. I was blaming everything on the cyclosporine. She was better on Saturday morning before she had any meds but she had also had a 20mg pred on Thursday and it would not have been enough time to see the effects of the lower dose of pred coming out yet.
Now that she is staying on the same dose of pred and has been on it for a bit I think I will have a better picture to assess in terms of exactly what side effects are related to the cyclosporine.
If she gets worse over the weekend break I will insist on looking into hypothyroidism and reducing the cyclosporine. As then there should not be the possible factor of the pred reduction involved in causing the symptoms.
The elevated liver enzymes scare me considerably. They have been one of my biggest concerns all along. I have been adamant to the vets about making sure her liver is okay.
I am Especially worried since the alt increased when we added the cyclosporine in. But they are telling me that liver enzymes can go up and down all the time. Taking the bloods is only a snapshot in time and perhaps this time we have just caught pepper at a higher level of alt than previously seen. We did bloods 2 days later and her alt had increased from 307 to 375. My vet said that if it had been a considerable increase of 200-300 or more she would have been more concerned. She said that a dogs levels can change by up to 100 during the course of a day, depending on what time they were taken. I am super worried about her liver but my specialist is telling me that her levels are consistant with what she normally sees for dogs in peppers position. She also said that she has dogs that go much higher and they are fine.
I don't want pepper to have irreversible liver damage, but I would hope to think the specialist should know what she is talking about and wouldn't put peppers life at risk? Peppers alp level was 2672.
I don't want to make the wrong decision

[Catherine]

I really do sympathize with you. You want to trust your vet. You want what is best for Pepper and so many decisions to make. I can not advise you what to do, your vet may be great. But from my own experiences, with several vets AND a specialist I find that I can not trust them completely and so I check everything and spend ages trying to find things out myself.

With regard to Hypothyroidism, I have found that a lot of vets just seem to think the dog has to be overweight and lethargic to warrant testing! Even then they usually dismiss the likelihood of Hypothyroidism. There are many symptoms and once again I have had experience of a dog being Hypothyroid that was neither overweight nor lethargic. It may be that Pepper's thyroid is completely okay but it would have been helpful to have that ruled out in the beginning when she started with limping, skin problems etc. She would probably have to be off of steroids to get a true reading but someone else might know a bit more about that.

In the UK the laboratory that my vet uses has a normal range for ALT for 10 - 100. Whilst I can appreciate how the figures can vary from day to day, if my dog's ALT was normally 40 and the next it was 140 I would be worried! At the same time I do know that on certain medication and/or with some diseases, conditions the liver enzymes will increase and sometimes alarmingly. Then when the medication is reduced or the dog gets better the enzymes usually go back to normal.

All dogs are different and what one dog may be able to tolerate another may not and so anything should be tailored to Pepper.

If she was my dog and I had to keep her on the medication I would still want to check her blood regularly. Yes, the levels are only a "snapshot in time" but if they keep increasing I think that is telling something more.

Jo said IMPA is not a life threatening disease, so unlike something like AIHA, you do have the choice to re-evaluate Pepper's medication and diagnosis.

[Jo CIMDA]

Hi

I am happy for you now that you've got a  treatment plan worked out with your vet. 

Just to put your mind at rest, you should believe the specialist when he/she says not to worry about the liver enzymes at this stage.  I don't think I can recall any dog on long term steroids that has ended up with permanent liver damage.  Usually when the drugs are reduced considerably the liver enzymes will drastically reduce and the liver and its function will eventually return to normal. 

Try to relax about it over the weekend and take a fresh look again next week.  I'm sure Pepper knows when you are anxious.

Happy Easter!

Jo

[BrookeR]

Jo, do you feel 10mg every second day (what pep is on now) for pepper (20kg) is a low enough dose of pred to show decrease in her liver enzymes and start rejuvenating ? Yes she is also on the cyclosporine though which can be increasing them.
My understanding is the specialist is looking at keeping her on this pred dose now for the arthritis. So if want to decrease turner we would need to work out alternatives to treat her arthritis.

Catherine, I am still very worried about her liver levels and the suggestion of not checking them does not sit well with me at all. When we get her to the 200mg dose of cyclosporine I want to insist on doing her bloods again and checking them. I know the specialist doesn't want to, but If her levels are still high or increasing I want to try some things to reduce the amount of cyclosporine she is having. I.e  give the cyclo to her without food  and/or try with the grapefruit juice or another drug that interacts with cyclosporine and allows less to be used.

[Jo CIMDA]

Hi

The duration of biological effect of pred is 12-36 hours, so if given every other day you have at least 12 hours before the next dose which allows the body systems to recover - so it has to be good.  You should see some reduction in liver enzymes, although the lower the dose of pred the more improvement will be seen.   I would expect the specialist to continue to reduce the pred as the cyclosporin reaches it full potential.

I don't think the specialist will want to keep Pepper on pred for her arthritis.  It might be an anti inflammatory but it is not used for arthritis because decreases calcium and inhibits Vitamin D absorption, and it also affects all other systems.  Much better to help arthritis symptoms by using an non steroidal anti inflammatory - but you can't mix the two drugs.

How about having a chat with the vet about giving Pepper  a joint supplement now.


Jo

[BrookeR]

Thanks Jo. I spoke to the vet today when Pep had acupuncture about a joint supplement and she is going to look into which may be best for pepper. Hopefully we can start her on one after Easter.

When I spoke to the specialist last weekend she did say something about anti inflammatories and that Pep would have to be off the pred for at least 5 days before starting them. I thought my vet had since said to me that the specialist wanted to keep her on the pred. But I may have misheard her, she may have meant (like you said) just until the cyclosporine was up and working to full effect.

I had read that cyclosporine can be used to treat rheumatoid arthritis. So I'm wondering if it will help her at all?
Is there any danger with giving her non steroidal anti inflammatories in regards to triggering the polyarthritis?  I also wasn't sure if the arthritis (pentosan) injections are safe for impa dogs?

[Jo CIMDA]

Hi

Rheumatoid arthritis is an autoimmune disease and is different to osteoarthritis, which I presume Pepper has so, Pentosan or another anti- inflammatory would be the way to go - with supplements.  Anything can trigger an autoimmune response but you just have to take the chance sometimes.  When you have an AI dog you are faced with many dilemmas throughout their life, such as to spay or not to spay, but you just have to go with the best thing at the time to give a better quality of life. 

You will get there in the end!

Jo

[Clover]

How is Pepper doing?