Cassie - my Whippet

[Rodgerr]

Really looking really looking for advice . My 9 year old Whippet Cassie was diagnosed with idiopathic chronic rhinitis 18 months ago. She has suffered quite a lot of infections for which she has been treated with both antibiotics and steroids. Neither help greatly. Five months ago she presented with a very high temperature lethargy loss of appetite and the vet after a week of trying to get her temp down took a leap of faith and gave her a high dose of steroids . Her temperature came down almost immediately and within days she was back to herself. Two weeks ago within the space of an houtbshe went from a healthy dog to s very poorly dog. We took her to an emergent vet who suspected a gastro problem. The following day we took her to our own vet for a check over and for a day or two she seemed to recover. Last Tuesday she relapsed and we took her back to the vets. Her temp was 41c and so poorly they kept her in and put her on a drip together with antibiotics. Each night she came home and each morning after a slight recovery was backbthe same. Saturday our vet who closes Sunday's was worried about leaving her over the weekend so suggested an emergency referral to hospital. Yesterday they did bloods X-rays scans and found slight scarring of the lung and an enlarged spleen. Temp still all over the place. The specialist said it was most likely mediated immune disease but nothing conclusive. The next stage would be cat scan and more invasive tests to determine what is wrong. I suggested given her history and what happened five months ago that could we try a high dose of steroids first as given the same symptoms then this worked. I'm not sure what further tests would have achieved as he said he was confident she did not have an infectious disease or a tumour. She is starting her steroid treatment today. She is still in hospital. Has anyone on the forum had a similar experience. She is been treat for an
Auto immune condition but unlike some of the posts I have seen without a definite diagnosis.

[Jo CIMDA]

Hi

I'm sorry Cassie hasn't been well.  There are many dogs with symptoms like Cassie's who never get a definitive diagnosis for an AI disease but when treated speculatively they pick up remarkably quickly and a presumptive diagnosis of AI disease is made.   This isn't that unusual.  Also, some Whippets are known to be genetically predisposed to AI disease, so this is another good reason to treat speculatively.

The good news is you know what to do to resolve the clinical signs, so I think you are on the right track.

I don't know what drug regimen she has been on in the past, but as they are now treating this as an autoimmune disease then she needs to be on the correct protocol.  Prof Michael J Day  is based at Langford Vet School, Bristol.  He is among the top immunologists in the world and his is the best protocol I have come across.   The theory behind successful  immunosuppressive treatment is to use as much as is required to suppress the immune system and no more (so not the highest immunosuppressive dose and not below 1mg/kg/12hrs))  and for as short duration of time as possible, and the protocol below is a good example.


Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based 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.

Cassie should also be in a gastroprotectant to protect her tummy from the side effects of the drugs. Omeprazole or Ranitidine are most often used.

If Cassie is on the correct protocol then I hope she will reach remission and will be able to come off medication but this can take 6+ months, but it will be worth it.

Jo

[Rodgerr]

Great news the steroids worked, she is off the drip and recovering. We now need to make sure that long term we keep her well. Thanks for the information about omneprazole I will make sure she gets this. Remarkable how she went from
being a very sick dog to more like herself in just 24 hours.

[Jo CIMDA]

Great news indeed!!!!

I don't think there is any doubt that Cassie has some sort of inflammatory AI disease and this is the way to go.  Just make sure that a similar protocol to Prof Day's is followed.  Some vets will put the dog on steroids for a week or so and then reduce.  This is not the way to go.  I am hoping that she is at a good referral practice and they will treat her accordingly.

What to expect?  Well, assuming that she will be on the correct drug regimen, then you can expect her to reach remission.  If she relapses during the reducing drug regimen, then you will have to raise the prednisolone (if that is what she is being treated with) up to the previous dose and hopefully this will stop the relapse and she will be back on track.  The aim is to take her off the steroids, but if this cannot be achieved then she will probably remain on a low every other day dose.  She may relapse from time to time but you now know to use an immunosuppressive dose of steroids to start the remission process.  She will feel so much better now. 

I had a dog with SLE (a multi-systemic AI disease)  and he would relapse from time to time. Fortunately, I recognised the signs and increased the preds and within 4 hours he would be up on his feet and back to normal again.  It can work well.

Cassie will be home soon.

Jo

[Rodgerr]

What a great site really appreciate the support . It's difficult to explain how helpless you feel when your pet is so poorly and there doesn't seem a way forward. Cassie is such a lovely dog and it was so difficult for my familynto watch her struggle with an unknown illness. We just hope we can give her a lot more years of good quality life.should get her home tomorrow - our Lab has definitely missed her.

[Rodgerr]

Cassie has responded well to treatment and the referral practice has indicated that she will have a blood test prior to each reduction in steroids. Just wanted to ask if any of the forum members have experience of having a pet with both IMD together with idiopathic chronic rhinitis. Poor Cassie has now got both. She has good days and bad with the rhinitis but always has a nasal discharge. We constantly have to be alert to the discharge being infected and now also have to gauge when she is unwell which of her conditions is the cause.

[Jo CIMDA]

Hi

It is likely that Cassie has a multi-systemic AI disease which includes Lymphocytic-plasmacytic rhinitis, but rhinitis can be a result of many different things, such as fungal or bacterial infection, and it isn't always easy to identify the cause. 

AI disease can occur in isolation, or two or three or even more different AI diseases can be evident at the same time.  In these cases any number of different body systems can become involved, and the longer treatment is postponed the more systems can be affected. 

Now she is being treated with, I presume immunosuppressive drugs, I hope the rhinitis will clear up but if it doesn't then you might have to investigate further.   Is she on antibiotics as well as the drugs that address the AI disease? If she isn't then it might be worth putting her on a course. 

Jo

[Rodgerr]

Cassie had full investigations for rhinitis two years ago and it was classed as idiopathic - unknown cause. More worryingly the vet a medicine specialist reduced her dose from 20mg to 10mg on Thursday and this morning she has had a relapse. I did tell the vet about Profesdor Days protocol but he hasn't followed it. We have upped her dose back to original and are hoping to see an improvement over the next few hours otherwise it's another trip back to the vets.

[Jo CIMDA]

She should respond to the higher dose and as long as she is coping with the side effects of the preds then you can prolong this dose and then take it much slower.  Reductions of preds by 50% was more common place many years ago, but anecdotal evidence suggests that reducing preds by 25% seems to yield much better results and achieve remission more often.

The side effects should be monitored daily by the owner and when the 14 day period arrives, look at Cassie and see if you can eek the duration out to 16 days, then 18 days and 21 days etc., then lower the dose.  If the side effects allow then eking it out like this seems to achieve better results. See the article 'What to expect when treatment has started'.

It has to be a balance between resolution of the disease and the side effects of the preds.  If necessary another immunosuppressive drug such as Azathioprine can be added to the regimen and this might allow you to lower the preds more successfully.

I hope Cassie improves very soon.  She responded to the preds the first time around and so she should respond this time as well.

Jo

[Rodgerr]

Much improved 4 hours after giving her the previous higher dose. Her respiration is still a little raised but she is eating again. I intend to print off  Professor Day's protocol and insist to my vet that this is what she will follow. Wished I'd gone with my heart not my head. I felt the reduction in her  meds was too drastic.

[Jo CIMDA]

Great news!  I once had a dog with SLE.  I could never get him off of steroids completely, but he had a good quality of life - quite normal playing with the others.  He used to relapse about every 9 months and I recognised the signs and immediately raised his preds to an immunosuppressive dose and, like Cassie, he would show remarkable signs of improvement after 4 hours.  I would gradually wean the dose of preds down again and he would be fine for another 9 months.

Immunosuppressive protocols vary but the Michael J Day protocol is the one that I think achieved the best results.

I am so pleased she picked up and within the expected time too, so you know what is needed now.

Jo

[Rodgerr]

Really appreciate your insight and consideration. I have one more question. As Cassie relapsed in the middle of her treatment do we start the protocol from scratch? That is another 10-21 days on full dose before we reduce it to 75%. Thanks.

[Jo CIMDA]

As Cassie relapsed in the middle of her treatment do we start the protocol from scratch? That is another 10-21 days on full dose before we reduce it to 75%.

The answer is no.  When a relapse occurs in the middle of treatment, as a result of lowering the preds too soon, then usually increasing the dose back to the previous dose that controlled the disease, will produce enough immunosuppression to bring the disease under control again.   Then, when you are ready to reduce the dose (after 14-21 days) the reduction should be less than before, ie., instead of a 50% reduction you should reduce it by 25% - assuming she is coping with the side effects of the drugs. You should never try to play 'catch-up' with the original drug regime and drastically reduce it in one go. If you did that then I would expect her to relapse again.

Relapsing in the middle of treatment is different to a relapse at the end of treatment.  If a relapse occurs at the end of treatment, when the pred dose is very low or given every other day, it is likely that the dog was in remission but has encountered a trigger, so the increase should be back up to an immunosuppressive dose. 

When a relapse occurs in the middle of treatment, the dog had not achieved a state of remission, so the preds are usually increased back to the previous dose that was controlling the disease.

With a dog like Cassie, where you don't know what AI disease she has and in fact several systems could be affected, it might be prudent to add a combination drug now, especially as she relapsed in the middle of the treatment regimen.  Adding another immunosuppressive drug will allow you to reduce the preds more efficiently and maintain a good level of immunosuppression. You might discuss adding Azathioprine with your vet.  Preds and Aza' are a very good combination drug.  Aza doesn't start to work for 10 days and it can take up to 6 weeks to have full effect.

Jo

[Rodgerr]

Thanks. The previous dose was the first dose. I think this has been reduced too soon and by too much. From her initial dose of 20mg to 10mg after only been on 20mg for 10 days. So should she be back on 20mg for another 14 to 21 days? The vet is calling me with the results of blood tests tomorrow so I will ask him about Aza. Cassie has had diarrhoea today so I'm also worried the drugs are having this side effect.

[Jo CIMDA]

Hi

10 days is not long enough to bring the disease into remission, especially as this is the first dose.

20mg of prednisolone a day is an immunosuppressive dose for a dog weighing 10kg.  If Cassie weighs more than this then she needs to be increased to 1mg/kg/12hrs prednisolone to be an immunosuppressive dose. 

The duration should be a minimum of 10 days, but initially the duration is usually for lot longer to ensure remission.  At all times the dose and duration must be assessed with the side effects of the drugs, this way you can eek out the duration if the dog is coping well or you can reduce it earlier if necessary if the side effects are becoming a problem.

The problem you will find, if a dog isn't on an immunosuppressive dose of steroids, is it will not achieve the aim of suppressing the immune system significantly enough to bring the disease under control and into remission.  All that happens is the dog will continually relapse and more and more steroids are used in the long term, which means more side effects.  It is far better to make the decision to put the dog on the lowest immunosuppressive dose from the start and follow the regimen - or at least use it as a guide. 

Sometimes, when on steroids, diarrhoea can occur because dog can get an infection such as campylobacter and this will need a course of antibiotics. 

Mention the diarrhoea to your vet and perhaps get some Prokolin or even metronidazole antibiotic.

Jo