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Author Topic: Triscuit - the gremlin  (Read 417 times)

mogulman

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Triscuit - the gremlin
« on: May 10, 2017, 03:15:29 PM »

Triscuit is our 12 year old Pug/Norfolk Terrier mix.    She looks like a fuzzy gremlin.   Some people see her and say.."wow..she looks interesting..".  We think she's cute though.   She's about 19 lbs.

About a year and a half ago, she started having health issues.  She was walking really slow.  Not eating too much.  Wouldn't go up or down stairs.  Down was harder for her then up.

We brought her to our local Vet.  We tried some things (Prednesone for a while) for 2-3 weeks and she got better, but then she got worse again.   
We brought her to a specialty animal clinic about a year ago.  They determined that she had Pulmonary Hypertension.  She is on 20mg Sildenafil 2x daily for that.   
The Sildenafil didn't really help though.  She is still taking the Sildenafil.

We tried a few more things with my local Vet but he couldn't figure anything out.  He suggested that maybe it was a spinal thing.  So we brought her to a specialty Veterany Neurologist 11/2016.  He thought it might be something in her joints.  He did a joint tap $2000+ worth.  He figured out it was IMPA.

Since 11/16, she has been on Lefluenomide 20mg 1x day and Dexamethasone.  Dexamethasone started at 1mg 2x daily.  Then went down to 1x daily, then .5mg daily.   Then .5mg  every other day.  Around 3/2017, she was on .5 every 3rd day.   She seemed to be doing pretty well.  Although I think she was doing a little worse on .5 every 3rd day.

About 3-4 weeks ago, she started getting some circular black patches on her skin with the fur falling away.   Our local vet tried some antibiotics and special shampoo.   That didn't help.  I read some stuff on the internet and thought maybe it was the Lefluenomide.  So I tried taking her off that for about 7 days.  The black spots did actually go away...but that was a big mistake.  Now the issues with her joints came back.  So I put her back on the Lefluenomide.

Went to see a vet dermatologies (I didn't even know there was a thing).  She thinks the skin issue might be a bacteria or fungus that the just didn't respond to the antibiotic my original vet gave her.   So she sent some samples away to be tested last week.  Still waiting for those to come back.  In the mean time, she gave us some Clyndamiacin 75mg 2x daily to take.

So in the meantime, Triscuits, walking and attitude has gotten worse.  She has been taking .5mg Dexamethasone  every 3rd day and Lefluenomide 20mg daily.  The problem is that the original vet that prescribed these medications (the vet neurologist) is booked out until July.   They said I could bring my dog and leave her there for a day and then maybe they can get to her, but it will cost extra.   This vet is about an hour drive away, each way.   My local vet doesn't know too much about IMPA.  He said I should probably see a specialist to figure out what to do.  He did say if he was going to guess, he would go back to a higher dosage of Dexamethasone.

So...now I'm kind of at a crossroad...
  • Try increasing the dosage of Dexamethasone.  Maybe .5mg every other day, every day, or even going back to 1mg every day or 2x/day and slowly go back down again
  • Find another specialty vet nearby that actually has availability to see the dog.   Maybe a Vet Orthopedic?
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Jo CIMDA

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Re: Triscuit - the gremlin
« Reply #1 on: May 10, 2017, 05:16:40 PM »

Hi and welcome

If you are pretty sure that Triscuit has IMPA, and therefore joint taps are really unnecessary,  then I don't see the need to travel a long way or spend lots of $ seeing a specialist when all your vet has to do is to put her back on to the correct drug, and dose, to suppress her immune system to get the IMPA back under control. 

IMPA responds very well to glucocorticoid steroids.  The usual glucocorticoid steroid used by vets in the treatment of autoimmune disease is prednisolone.  Dexamethasone is also a glucocorticoid steroid, and it is 6 times more potent than prednisolone and its duration of effect is much longer 36-72 hours, whereas the duration of effect of prednisolone is 12-36 hours. Both prednisolone and dexamethasone will significantly suppress the immune system if used in correct doses.  The aim of using these drugs is to suppress the immune system, and in doing so the disease will be under control.  When the dog is weaned down to a low dose, or off altogether, the immune system has returned to normal function and the disease is in remission.

The advantage of using prednisolone, over dexamethasone, is the shorter duration of action of prednisolone allows the adrenal glands to gradually kick back in when going to every other day dosing, and function normally again.    When weaning down from using dexamethasone, even when given every other day the adrenal glands don't get a chance to become active before the next dose is due.

Leflunomide is a good immunosuppressive drug that is being used more often these days in the treatment of AI disease, especially IMPA. It costs a lot more than prednisolone though, and I would imagine more than dexamethasone.  Perhaps Leflunomide was prescribed because she has pulmonary hypertension.

So really you have a choice of what drugs to use but the dose has to be high enough to suppress the immune system again.
I am sure you have looked on the internet but her are a couple of websites that are worth looking at.   

http://www.animalhealthcarecenterofhershey.com/medical%20handouts/Immune-Mediated%20Polyarthritis%20in%20Dogs.pdf

http://vetspecialists.com/immune-mediated-polyarthritis-impa/

If you do decide to use prednisolone, this is the best protocol I have come across and it can be confidently used as a guide.   Prof Day is among the top veterinary specialist in the world.

Example: Reduction Protocol for prednisolone:

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.

Have a chat with your regular vet and see if he is willing to treat Triscuit himself.  It's shouldn't be too difficult to bring under control if the correct dose of drug/s is used and for the correct duration of time. 

Jo
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mogulman

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Re: Triscuit - the gremlin
« Reply #2 on: May 10, 2017, 05:51:21 PM »

Thanks..I'm going to talk to my Vet on Monday.  Thanks.
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mogulman

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Re: Triscuit - the gremlin
« Reply #3 on: July 06, 2017, 04:35:30 PM »

Ok.  So triscuit started out with 1.5 5mg prenisolone tablets every 12h  starting on 6/5/17.  She is also taking Lefluenomide 20mg 1x daily.   The vet seemed to think the Lefluenomide helps. 
She also takes 10mg femotidine to ease her stomach.

We are slowly tapering her down in the prednisolone.   Currently. On 7/6/17 she is on .5 5mg tablet every 12 hours of prednisoloneand still taking the Lefluenomide and femotidine.

She seems to be doing very well, joint wise. 

She has something else going on now.   Places where her skin has rashes or sores.  She is losing fur in these areas.  The vet doesn't think it's related to the meds.   He sent off her skin and they think it's vasculitis.   They want to give her some other meds or increase her anitbiotics for this too.   Here is what they are considering:
1. Cyclosporine 50mg: Give 1 capsule orally once daily. Freeze capsules and give them frozen, monitor for possible vomiting
and diarrhea as a side effect. M

2. Pentoxiphyline 400mg: Give 1/4 of a tablet orally every 12 hours. Vomiting and diarrhea are potential side effects. Monthly

I haven't ordered any yet, as triscuit doesn't really seem concerned about the skin condition.   She isn't scratching or anything.  I just hate to give her tons of meds. 
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Jo CIMDA

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Re: Triscuit - the gremlin
« Reply #4 on: July 06, 2017, 05:25:06 PM »

Hi

It is good that Triscuit has responded well to the prednisolone and leflunomide.

Where are these skin problems and what do they look like?  Prednisolone can cause hair to fall out and for the skin to become thin which often leads to  things like parasitic, fungal and bacterial infections. Sometimes you can have all three causes at the same time.

When the immune system is suppressed the skin is susceptible to these outside influences and also if the dog licks or chews at the skin they can do a lot of damage and cause secondary infection which makes matters worse. I presume the laboratory has checked for all of the above possibilities and as they have started her on antibiotics I presume there is bacteria present.

Vasculitis can also cause red circles called weals, and this is typical with vasculitis, but rashes and sores I'm not sure. I have had a dog with vasculitis and I know the look of the skin marks well.  Take a look on the internet at some pictures of vasculitis in the dog to see if it is similar to Triscuit's.

Has your vet considered using essential fatty acids, such as fish oil and evening primrose oil? EFA's are used in therapeutic doses for the treatment of AI skin disease and they are known to be steroid sparing, meaning that they play an active role in controlling the immune system in a similar way to using steroids. So they are a good addition to make, and also fish oil works as an anti-inflammatory.   Natural Vitamin E is also used in therapeutic doses and this encourages new cell growth. All good for skin problems.

I feel I would want to know for sure if the problem was vasculitis and not a drug induced skin problem.  If it is vasculitis  then why don't they just increase the prednisolone back up to a higher dose again to bring this under control rather than introduce more drugs? 

I have never heard of giving Cyclosporin in frozen capsules before - can you tell my why it is frozen?

Pentoxifylline is used to manage AI skin disease, but again I would want to be sure that it is AI related,  and I feel as she is already having preds and Leflunomide I would rather add pentoxifylline than Cyclosporin - only my personal opinion. 

I do hope you can resolve this soon.

Jo
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mogulman

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Re: Triscuit - the gremlin
« Reply #5 on: July 06, 2017, 05:43:34 PM »

She doesn't lick her skin.  Some of the places it is happening is unreachable for her to lick.  We also tried to antibiotics for about a month and that didn't seem to help.  They didn't see any fungal or bacterial stuff on her skin when they cultured it.

The dermatologist does seem to think the rashes could be related to AI.  Her is her complete diagnosis:
Hi Jeff,

I left you a voicemail but wanted to go ahead and send this information via e-mail as well. We received Triscuitís biopsy results

this morning, and the diagnosis is one of vasculitis. Basically her blood vessels have become inflamed, and instead of being a

nice smooth garden hose are more like a rusty pipe. The red blood cells get stuck in this rusty pipe and donít make it to the

surface of the skin to provide nutrients like they should.

Vasculitis often sits within the spectrum of autoimmune disease, and may be an extension of her other autoimune disease.

Likewise something like an underlying cancer in the body can inflame the vessels, as can various other things. She is already

on medications for one autoimmune disease, so one option would be increasing the dose of those medications (steroids,

mycophenolate), though with her cardiac disease I know we are cautious of too much steroid. The other option that I would be

leaning more towards is adding in other medications. Cyclosporine is a drug that helps in autoimmune diseases, and

pentoxiphyline acts on the red blood cells to make them more flexible so they donít get caught in those inflamed vessels.

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mogulman

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Re: Triscuit - the gremlin
« Reply #6 on: July 06, 2017, 05:53:33 PM »

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mogulman

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Re: Triscuit - the gremlin
« Reply #7 on: July 06, 2017, 06:02:43 PM »

Also.  The skin issues seems to be getting progressively worse but have gotten better at times. 

I personally think it is related to the Lefluenomide, but maybe not. 

She has the skin issue a few months after she started with dexamethasone and now that she has switched to prednisone.  So I'm thinking it's got to be the meds or her AI with her joints somehow spread to her skin?

She didn't have any skin issues before she started taking any of the meds 6 months ago.
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Jo CIMDA

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Re: Triscuit - the gremlin
« Reply #8 on: July 07, 2017, 10:17:18 AM »

Hi

Triscuit looks a real sweetie.  Thanks for the pictures.

Vasculitis can be cause by so many other things beside an autoimmune response, such as:  hypersensitivity to food, infection, malignancy, vaccination etc........... so when there are lots of possible causes you have to look that the most likely given the recent history of the dog. 

 I do wonder as Triscuit was on immunosuppressive treatment why an immune mediated vasculitis would have flared up at that time?  Surely, the treatment she was on should have been enough to stop any immune mediated disease developing?  Perhaps you could ask your vet, if they think it is immune mediated then why would this have occurred when she was on immunosuppressive therapy.

She is hyper-pigmented and this can occur, along with thin skin and lesions, with drug induced Cushing's syndrome which is typical in a dog that has been on dexamethasone or prednisolone, so could this vasculitis be as a result of being on steroids?

If you don't want to go down the route of introducing another strong drug like Cyclosporin, your vet might consider a course of doxycycline (or tetracycline) and niacinamide.  Doxycycline, or tetracycline, with niacinamide can be used for the treatment of AI skin disease and it is a way of bringing the skin disease under control and into remission without the use of steroids.  It takes a few weeks to have an effect and the treatment will be ongoing for some months.

Maybe you can ask more questions before deciding what to do next.

Jo

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mogulman

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Re: Triscuit - the gremlin
« Reply #9 on: July 07, 2017, 01:25:02 PM »

Here is a better pic of our fuzzy pug



https://goo.gl/photos/mKZggho5WNoxtpHp8
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Jo CIMDA

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Re: Triscuit - the gremlin
« Reply #10 on: July 07, 2017, 06:56:12 PM »

Thank you for that lovely pic of Triscuit. She looks a real character for sure.  I bet she keeps you on your toes!

She brought a big smile to my face.

Jo
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mogulman

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Re: Triscuit - the gremlin
« Reply #11 on: July 11, 2017, 04:46:51 PM »

Yeah...   Triscuit is a pretty crazy dog when she's healthy.   We love her and wish we could get some of this under control. 

She does seem to be doing very well on the Prednisolone.   Wish we could figure out the skin/fur issue as it seems to be getting worse.   I'm thinking that increasing the steriod isn't going to help because she has already been on higher dosages and it didn't seem to help before.    She has been at the starting dosage for both dexamethasone and prednisolone over the time period and she still had these issues with her skin.  So I don't think higher steriods will help, but I could be wrong.

I talked some more to the vet, and she said we could try replacing the  leflunomide with Myophenolote or Cycolosporine.

 
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mogulman

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Re: Triscuit - the gremlin
« Reply #12 on: November 08, 2017, 02:52:28 PM »

Ok.. It's been about 4 months.  Triscuit was on Penotxifylline for the vasculitis in her skin/fur.  Not sure if it really helped, but her fur/skin got better.  She ran out of this med about a month ago and the issue hasn't come back.

For the IMPA, she is down to 2.5mg Prednisolone every 3rd day.  She has been down to this dosage since 9/26.  She is also taking 20mg Leufluenomide.   Her joint issues are doing great.

I guess at this point, should I talk to my Vet about discontinuing the Prednisolone?  or do I keep giving it to her.  I think this is probably the smallest dosage I could give her.

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Jo CIMDA

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Re: Triscuit - the gremlin
« Reply #13 on: November 08, 2017, 03:44:15 PM »

That all sounds very good and as Triscuit is still on leflunomide then you can certainly consider leaving off the pred,  or if you want to you can either reduce the small dose further to say a quarter of a 5mg tablet or go to  2.5mg every fourth day and then every fifth day etc...

When the dose of prednisolone is very low there are many different ways of reducing it - and none are wrong. Therapeutically this low dose isn't doing much but as her body is very used to having this small amount of pred then taking it really slow at this stage, to enable her body to gradually get used to being without a pred supplement, is a good way forward.

Great update!

Jo

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