My Sadie - IMPA

[Trish]

It's funny that I never found this forum in the early days of our journey.

Last June, our 7.5 year old terrier mix, Sadie, started limping. It was an odd limp, because she wasn't always limping on the same leg. So off to the vet we went. She was prescribed painkillers, and sent home. A week later, the limp was worse, she was growing lethargic, and wasn't really eating well. Back to the vet we went, she had a slight fever and a high white blood cell count. The vet thought she must have an infection of some sort, so she was put on antibiotics. I'm not blaming this clinic: most clinics see heathy animals, not immune diseases. We also tried to tempt her appitite by soaking her food in chicken broth, but by Friday, we were hand feeding her. That Saturday I had a 24-hour work shift. That evening, my husband called; Sadie was worse and he was worried.I was busy, so I thought he was just being a worrywart.

When I arrived home at 7am on Sunday, it was obvious she was in very rough shape. I told my husband to call the clinic, surely they would have an emergency vet clinic number on their answering machine. They did, a specialty emergency hospital in Tacoma, and we went. At this point, Sadie had a very high fever, and was flinching in pain every time the car took a corner or I moved her.

The staff took her back immediately. Her temperature was 105.5F, and she was severely dehydrated. We were almost certain that we would have to euthanize her, but I wanted her pain free first. The doctor who saw us told us she thought Sadie had IMPA, but they would need to confirm the diagnosis. They let us see her before we left, and when our girl realized we were leaving, she tried to follow, whimpering in pain and dragging her IV. It was heartbreaking. She stayed for three days, and was examined by two of the specialists. She had a joint tap and a spinal tap to rule out meningitis. One of the specialists wanted to do an MRI, but conceded that the overwhelming evidence pointed at IMPA. She was placed on 10mg Prednisone and 50mg of Cyclosporine twice a day.

The first taper of the Prednisone went well. Around this time, we moved 1600 miles for our jobs. (We are in the US Army) The vet on post had come from the same post we had, and had worked with the hospital, so we were very happy to work with her. The second Prednisone taper did not go as well. We went down to 5mg twice a day, the limp returned and Sadie started refusing food and water again. This time, she spent a week in the vet office during the day getting IV fluids and pain meds, becoming a favorite of the office staff. We also went all the way back up to 10mg of Prednisone twice a day, as well as Enalapril, as her kidney numbers were not looking good. The vet asked us to put her on low protein food, as well as giving her fish oil.

At the end of November, my husband asked me what the spots on her back were. Why, oozing sores! Sadie had an approximately six-inch subcutaneous infection on her back.  While the vet was examining her, a fingertip sized patch of hide just sloughed off. We ended up with some more antibiotics, which she reacted well to. Apparently, Prednisone increases skin fragility and susceptibility to skin and urinary tract infections. (We're just happy that we are dealing with skin infections, rather than UTIs) At the same time we tried the Prednisone taper again, down to 10 and 5 mg. In December, we tapered down to 5 and 5 mg, this time successfully.  We've had two reoccurrences of the skin infection, and she lost all of the hair on that area. Combined with the shaved patches from the spinal tap and the joint taps and the IVs, which haven't grown back, the utter muscle wasting of her legs and head, she's a rather unfortunate looking dog!

This last reduction of Prednisone has given us our girl back. She still drinks excessively, but she is a lot more active, interested in the goings on in the yard, and is happily pestering our Coonhound and us for attention. We're hoping to eventually taper down to 2.5mg every other day. The vet is apprehensive, but hopeful. It's been a long journey, and is not over yet, but there is hope on the horizon.

[Jo CIMDA]

Hi

Thank you so much for you account of Sadie's journey.  Reading different stories really helps owners who are newbies to looking after a dog with an autoimmune disease.   It is so good to read that Sadie is doing well. 

The effects of prednisolone can be a problem - no such thing as a free lunch - but steroids are the most efficient immunosuppressive and they act within hours, unlike so many other immunosuppressive drugs.  When Sadie is down to every other day dosing, her body systems will start to recover and behave normally again.  She won't be as thirsty nor as hungry.  Her hair will regrow back but sometimes you have to wait until a new growth cycle which may be many months.  I have pictures of a dog that is bald from the waist back, as a result of high doses of steroids, and then pictures of the same dog 9 months later with a wonderful coat.  I have experienced this with my dogs too, so you may have to wait but Sadie will look like her old self again in time.

Should you have to put Sadie back on an immunosuppressive dose of prednisolone in the future, please consider the immunosuppressive drug protocol by Michael J Day. It is the best protocol I have come across and can be used as a guide.

Jo

Ref: Clinical Immunology of the Dog & Cat by Michael J Day  – Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.

Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

This example is base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h                  10-28 days
0.25mg/kg/q24h                  10-28 days
0.25-0.5mg/kg/  Every other day   at least 21 days
0.25-0.5 mg/kg/ Every third day    at least 21 days

[Trish]

We've had a little bit of a setback with our girl.

We've been trying to wean down her Prednisone. A couple weeks ago, the vet reluctantly agreed to move from 5mg morning and evening to 5mg in the morning only. (She weighs close to 15kg, so this is still a good sized dose.) It became apparent that she metabolizes Prednisone quite quickly. She started becoming reluctant to get up in the mornings, and appeared to be in pain. Yesterday, she was limping very hard on a front leg. Within 3 hours of her morning dose, she was her usual bouncy self. Her temperature never rose, and she continued to eat and drink, so we didn't hit a crisis event. So last night, we gave her another 5mg. This morning, she got up early, charged at her food, charged for the door, and is acting about as normal as she gets.

On the plus side, her kidney and creatine numbers were better than previously, but she's still losing hair (alopecia from the Prednisone) and had a nasty skin infection for about two months.

So we'll continue on for another month or so, and wait for the 5mg Pred to run out. (Some of it is split 10mg tabs) once it does, we'll look at reducing to 2.5mg twice a day.

[Jo CIMDA]

Hi

I'm sorry Sadie has relapsed but glad she is responding to the steroids.  I hope you get away with only giving her 10mg a day, often when a relapse occurs (which is common) the dose has to be raised significantly. 

I wouldn't be in a hurry to reduce the dose too quickly and when you do it would be better to reduce it by 25% and not 50%.  Anecdotally this works much better and it is in line with Prof. Day's excellent drug protocol. When you get down to low doses the the reduction can be taken  much slower without all the usual side effects and in the long term it often works out better.

Good luck.

Jo