iatrogenic cushings - pred treating immune mediated disorder & cannot reduce pred now

[Brooker]

Hello,
My 7 1/2 yr old English staffy was diagnosed with immune mediated polyarthritis on Christmas Eve, after a week in hospital having ever test the vets could think of. She has now been on high (immunosuppressant) doses of Prednisolone since (approx 2 months). She is now showing symptoms of iatrogenic cushings & had a blood test last week that backed this up. i.e alkaline phosphatase were elevated & elevated neutrophils. We were due to reduce her pred on Friday, but she has had two instances of showing lameness (likely to be due to the IMPA) in the last two weeks. We are concerned the IMPA is not under control and we may have to add another immunosuppressant drug such as Azathioprine with the pred.
If we add the Azathioprine we can reduce the pred down to a lower dose once the azathioprine is in her system. Yesterday we did X-rays to confirm that she had the non-erosive form of poly arthritis and to check there was nothing else going on that could be causing the intermittent lameness. There was no damage to the joints, but slight amounts of fluid evident in the joints. We are now waiting to hear back from the specialist to confirm whether she wants us to do another joint tap to see if the IMPA is under control. So basically she is going to need to stay on the presnisolone for a while yet regardless of the iatrogenic Cushing's and what it is doing to her body. I really want to start reducing the dose, but the vets keep assuring me that her impa is more life threatening & we need to get it under control first.
My girl is also a very allergic dog and has suffered with allergies for a number of years. One thing she is highly allergic to is dandelion. I would really like to try give her the best chance I can (in terms of the Cushings & having to stay on the pred for this extra time) by giving her some natural supplements. But I have to be very careful what I give her (due to her allergies) and cannot use any milk thistle supplements due to her dandelion allergy. I would love to hear if there is any other good liver supplements or anything anyone may be able to suggest to help prevent long term damage from the pred. It is horrible knowing that I am doing damage to her with the presnisolone, but I don't have any other option. All I can do is try find ways of minimising the extent of the damage.
It's been a very stressful & expensive few months, but I just want to do everything I possibly can to give her the best chance. She is a very special & unconditionally loved member of our family.
Any suggestions would be great. Thanks

[judymaggie]

Welcome! I am so sorry you and your pup have been going through such a difficult time. I am sure some of our in-house experts who have a lot more experience than I with regard to iatrogenic Cushing's will be along. I did have one suggestion with regard to a supplement for liver health: SAM-e. Here is a quote about SAM-e from the VCA Animal Hospital website:


The sulphur groups of SAMe are likewise metabolically important. Glutathione, a key detoxifier and antioxidant in the body, is made from SAMe. SAMe itself also functions as an antioxidant. These antioxidant and detoxifying properties result in SAMe being able to reduce liver damage such as cirrhosis.

SAMe has several other effects in the body. It plays a key role in the breakdown of estrogen; the synthesis of carnitine (important for adequate heart function); the synthesis of choline (important for cognition and brain function); the synthesis of melatonin, allowing sleep; the synthesis of nucleic acids so that cells can divide; the degradation of histamine (reduces inflammation); and the synthesis of collagen.

"...commonly used in osteoarthritis."
SAMe is also an analgesic (pain reliever), and this together with its ability to promote collagen and cartilage synthesis and its anti-inflammatory properties results in it being commonly used in osteoarthritis. The efficacy of SAMe in relieving arthritic pain has approached that of many NSAIDs in clinical trials.

Since SAM-e is an amino acid I would think that it would not interfere with your dog's allergies. I also wonder if it might not help relieve some pain from the polyarthritis. I give my Cushing's pup a SAMe/milk thistle combo which would not be appropriate for your dog.

[Dixie'sMom]

Hello to you and your pup and welcome to the forum. I was compelled to answer you because I am someone who also takes high doses of Azathioprine (Imuran) and steroids daily and have for years. Am I Cushingoid? Very. But because of my autoimmune disease this will probably be a lifetime regimen for me as well as your pup. In this case, please follow the advice of your vets and only taper the prednisone only when he/she is clinically ready to decrease due to the possibility of causing the autoimmune disease to flare/worsen. I've heard the others say on this forum that "sometimes we have to pick our battles" and that is true. You can only fight one war at a time so for now the focus needs to be getting the autoimmune disease under control. Your pup may always need some level of prednisone to manage the disease and could very well turn full blown Cushing's at some point in time since he/she is fairly young. On the other hand, he/she could go into remission which would be wonderful and we certainly don't want to rock that boat.

The folks on this forum are very knowledgeable and experienced with Cushing's disease and its symptoms and I am certain we can help you manage the symptoms. I will let them advise you on supplements because they have much more expertise than I. Could you please share with us what symptoms your pup has begun to experience? Also if there have been any abnormalities on his/her blood work and urine analysis it would be helpful if you could post those values with the reference ranges. Those numbers could also help the experts here to know if the steroids are stressing the kidneys or liver. Has your vet mentioned anything about high blood pressure?

And most important of all, what is your pup's name so I can quit calling him/her pup? :D

Again, welcome and we will do all we can to help.

[molly muffin]

Sam-E is a good alternative. Check with your vet, but I think it could be helpful. Just make sure to get one that is Only sam-e and not the combo of sam-e/milk thistle. I use one that is a breakable tablet and sam-e along with some vitamins and omegas. Omega 3 would be helpful probably too.

yes, I think that once you know for sure that your pup is stable, then the vets will look at lowering the dose of prednisone but that needs to be stable and then you want to taper the pred, under the vets guidance to where you can have manageable levels.

Welcome to the forum.

[Brooker]

Thank you everyone for your responses I just wrote a big thank you & explaination of all your questions and an update on what's been happening with pepper. When I clicked post reply it all vanished :(
It took me ages to type out, I will have to try again tomorrow to redo it. Probably best to use the computer next time and not my phone. Argh so frustrating!
In brief what figures are the most relevant to list in her blood test? I have a whole page of figures and I am not entirely sure which are most relevant. Other than her ALP is 2246 (normal is 1-120), her neut is 16.1 (normal 4.1-9.4) , WCC 18.1 (normal 6.0-14.0)
So annoyed I lost my previous post :(

[labblab]

Here's a very quick welcome from me with a link that may help keep you from losing replies in the future -- I know from experience how frustrating that can be!

http://www.k9cushings.com/forum/showthread.php?t=1329

Marianne

[Brooker]

Thanks heaps for the link Marianne that was a great help. I do not want to loose a reply like that again and have read through the link you sent. Hopefully I can prevent if happening now

[Dixie'sMom]

Ahhh.... Her name is Pepper. :D I also noticed in your first post you called her a her which I didn't catch before. *Sigh* Im on a roll with thinking everyone has a male lately. I'm so sorry.

When you get a chance to reply again, just post the abnormal results with the reference ranges. The way you did it in your other post is fine.

[Brooker]

The name sam e has came up a bit since I have been researching but I had just assumed that it all had milk thistle in it and didn't realise there was different combos. Thanks for bringing this to my attention, I will look into this further to see if it may be okay for peps allergies.
I have been giving her omega oils for some years now for her allergies & I had read that they were suitable also for her existing condition so I have continued their use.
I'm sorry to hear of your condition dixiesmom. But is positive to hear that you have it under control and have so for some years now.
The vet has not mentioned anything about peps blood pressure.
Do you notice when you change dose that it takes a while for your body to regulate itself? When I dropped back peppers dose from 2 tablets a day to 1 1/2 2-3 weeks ago for about 4 days she went insane drinking and was making an almost sandpaper sound in her mouth running her tongue backwards and forwards like her mouth was so so dry but then she seemed to settle again. The vet thought this was bizarre and that going down a dose should have the opposite effect. She has the pot bellied appearance and saddle back (but being a staffy she already had this look to a degree before pred more so than any other dog.) She also has thinning of the skin and I have noticed that her skin has become a bit flakey/dandruffy dry down her back the last week. She has had a few accidents with leaking bladder which she would never normally do. She is crazy hungry, thirsty and peeing lots. As well as being lethargic and depressed, not wanting to play or jump up on things.
Her last urine test a month ago was fine but she is due to have another this week and I will update you with results once they are through.

[Brooker]

Furthermore I have spoken to a holistic vet and made a few changes to her diet since her blood test. Nothing major as with a dog this sensitive it's best to take small steps. I haven't added anything new that she hasn't had I have just changed ratios and removed some things. The holistic vet recommended taking her off the dog biscuits (even though they were special expensive allergy ones) and removing all preservatives from her diet. I normally feed her twice a day with cooked mince and frozen vegies with a handful or so of biscuits after each meal. Since she was sick I had found out that the hypoallergenic biscuits she was previously on for a long time had very very small amounts of chicken in them that some dogs could still recognise. Pepper is allergic to chicken so I changed biscuits when I was made aware of this. I got her fp response ( salmon & potato ) ones but when reading about healthy foods lately I have read that potato has inflammatory properties and salmon wasn't good in terms of the cushings either. The holistic vet recommended I not use Frozen vegies anymore and to puree the vegies now instead of just cooking them in chunks. Apparently the body will absorb the nutrients of them better when puréed as opposed to in chunks. She also told me to give her half protein (beef- she normally eats this without a problem) and half vegies. Of the half vegies I am to give her half greens such as beans, broccoli & half sweet potato, carrot and pumpkin. I can also give her some fruit like banana as treats. She did mention some other things such as yoghurt and some additives but I wanted to start slow that way if something triggers her I should be able to figure out what it was. I have also changed to giving her 3 small meals a day and am giving her the best quality raw meat I can get her. As well as removing any fat chunks. I had read small meals often were better to keep the digestive system working properly and don't make it have to work too hard. Also it helps with her hunger as she thinks she is getting more. I read that raw seems to be the go in terms of her immune mediated problems as well as good for the liver/Cushings. When the meat is cooked it changes the protein and is just better raw for them. So I have been feeding her this for the last week and over the last couple of days I have noticed that she is not drinking or weeing nearly as much as she had been. She also seems a bit more perked up & I don't think her pot belly looks as bad. Most notably her drinking and weeing has settled right down. Do you think I am getting ahead of myself thinking that within a week this diet adjustment could be helping her Cushings? Does everything I am doing sound right? I have just been reading whatever I can about her conditions and gathering all the info together and making judgements based on what I think seems to make sense.

We are still waiting to hear back from the specialist as to what we are going to do next. I have fasted her the last 3 nights (on my local vets instructions) in hope the specialist will have got back to us through the night in case she wants to do the joint taps again. It is horrible fasting a dog on pred. They are so hungry and especially having to do it to her three nights in a row. She hates me at the moment :(
The vets seems to think it's the pred that is making pep depressed and sick now. The X-rays showed no damage to her joints and small amounts of fluid which they cannot be certain is not normal levels of fluid , without doing the tap. Her joints don't appear to be swollen so she is unsure why pepper has had a limp on two occasions that only lasted a few hours. Her last thoughts were reduce the pred dose and see what happens. She may relapse but she could also be partially relapsing now with the limp. Otherwise they think the limp is from an old injury, but I have told them she has never hurt herself before. The only problems she has ever had are immune related with her allergies. I am worried as I cannot see that there could be anything other than the impa causing the occasional lameness. I don't want her to relapse but don't want to have to put her through joint taps again. There is no easy choice.

[Renee]

Diet can be a rather hot button issue, and many people have differing opinions. Not using a commercially prepared diet is a personal choice, but keep in mind - a bad homemade diet (raw or cooked) is worse than the wost commercial diets available. This means, if you are doing your homemade diet wrong, you can do more damage than if you just fed the bad commercial crap.

Two things stood out to me in your diet:

One is that you don't talk about giving any calcium supplement. This is vitally important to the health of your dog. If she is not consuming raw meaty bones, then she absolutely needs calcium supplement. If your holistic vet has not addressed this with you, then I would question their overall competence in formulating a diet plan.

Second is that you are giving a ratio of 1:1 on meat vs. veggie/carb. This is probably much too low. Protein should make up 70% or more of the overall diet.

If you've eliminated the biscuits and started a more moisture rich diet, then it would make sense that water intake is down. It takes quite a bit of drinking on a dog's part to rehydrate kibble and biscuits. My dogs hardly ever drink water, since they are on a dehydrated raw diet (the honest kitchen).

[Brooker]

Yes her name is Pepper, and she is a girl. Don't worry about it she gets called a 'he' all the time. I think its just more common for people to call dogs a 'he' when they aren't sure of their sex.
Her abnormal results (other than the ones I already posted previously) as far as I can tell are:

GGT 63 (no normal range is given to compare) - H
ALT 132 ("). -H
Eos 0.0 (0.1-1.2) - L
Mono 1.1 (0.2-1.0) - H
Lymph 0.7 (0.9-3.6) - H
Band forms 0.2 (no normal range is given to compare) - H

[Brooker]

Yes my holistic vet did talk about giving her a calcium supplement. She wanted me to give her chicken bones, but she is allergic to chicken and I don't give her beef bones because being a staffy she always had a tendency to take two bites and then swallow. Regardless of how big the bone was. I was forever panicked about her choking as numerous times I have had to try and pull a lodged bone out of her throat whilst she was also in massive panic trying to claw at her mouth. Being on the pred too with the crazy hunger now I definetely would not trust her to eat a bone properly she would take it in one gulp. The holistic veg said that it was important and maybe we could just get some crushed up bones and put on her food. She was going to have a think about what to do & get back to me. I have not heard back from her yet. I had actually forgotten about it so thank you for reminding me I will chase her up about it. Do you have any suggestions of what we could give her?

In regards to the water intake, she has always eaten biscuits (prior to pred taking) and never drank so much then? But I guess the combination of the pred with the biscuits could make her more thirsty.

We have tried pepper on commercial diets throughout her life including those made specifically for allergy dogs. But I have always found she reponds better to natural home made food. At least I can be certain what is in it. For instance the dog biscuits she has been eating for years now that Multiple vets told me were fine for her allergies. I have recently found out actually have chicken in them. It is in very very small amounts, but apparently some percentage of dogs can still recognise the protein.
My girl has always been extremely sensitive and I would not be surprised at all that she recognised the protein in the biscuits. As we could never get her completely stable with her allergies.

But you are right I need to make sure she is getting the nutrients that she needs. I have always been more focused on doing the home made for her allergies to make sure she avoids the foods that she can't tolerate in her diet. But I haven't put as much focus on what foods she needs in her diet.
Thanks for your suggestions and reminding me about the calcium intake.

[Harley PoMMom]

Hi and a belated welcome to you and Pepper from me as well!

When I had my dogs diets formulated I used calcium carbonate powder, the brand I purchased was "NOW", here's a link: http://www.nowfoods.com/Calcium-Carbonate-Powder-12oz.htm

Hugs, Lori

[Renee]

I've used the same calcium supplement as Lori suggested.

There is a supplement made by Call of the Wild that includes calcium and other vitamin nutrients. It may have chicken though. I used that one for my most recent homecooking.

You can also just use ground egg shells.

[Dixie'sMom]

Thanks for posting Pepper's labs. The others here are good at reading them so hopefully someone will come along soon to share their thoughts.

As far as Pepper's diet there is really nothing I can add except to let her have as much water as she wants. The Cushing's symptoms will make her want to drink more (polydipsia) to excrete as much cortisol as she can. This is a natural function.

I agree with your vet. I would have thought that decreasing the Prednisone would have made her feel better. (It sure makes me feel better) How much was the decrease in dosage? more than 5 mg.? If so, it could be that the taper needs to go a bit slower so the adrenals can catch up as the Prednisone lowers. As for the dry mouth noises, I have no clue. That is a bizzare symptom. Could she have had something stuck in her tooth she was trying to work loose? I am glad to hear that with the change in diet she seems to be improving. Pureeing will allow her to absorb the nutrients faster but she will need some chunks of food to keep her belly feeling full and keep her from overeating. Choose low carlorie veggies that she enjoys and let her have a few chunks to keep that belly feeling full, if not at mealtime, then for snacks. Also a friend of mine had a boxer with bad arthritis and he was advised to give him 3 chucks of pineapple per day. There is something in pineapple that is good for the joints. Maybe this could be a snack she would enjoy if she isn't allergic to it? I know this is a challenge for you with all of her allergies. Yikes.

Thanks for the well wishes for my health. I'm hanging in there. Like Pepper, I have good days and bad days. The lower the prednisone goes, the better I feel. Folks think Prednisone gives you so much energy and helps make muscle. Maybe in the short term, but long term it just makes you feel lousy and weak and jittery and HUNGRY. When will Pepper be starting the Azathioprine?

[Brooker]

Thanks Lori & renee for your calcium supplement suggestion I will look into this. During my research this morning I had also read about the egg shells being good and I have given her eggs and egg shells in the past ( not for any health reasons just when we have been eating eggs I let her have some). So I know she is fine with them and thought that they may be a safe option.

[Harley PoMMom]

Since Pepper has an immune disorder, you may want to bake those egg shells before giving them to her, because of salmonella. Also, from what I read, dogs can't digest the calcium properly from the egg shell unless it is ground to a powder form.

[Brooker]

Yes the info I found about egg shells had said to bake and then crush in a blender to a powder. But I was going to double check with our holistic vet first before giving them to her anyway. Just to make sure.

[Brooker]

Yes everyone thinks pepper should be bulking up with muscle being on the steroids too. But they are thinking of a different group of steroids and that's not the case at all with presnisolone.
Pepper was on 2x 10mg tablets a day and I reduced her by half a tablet. So it was a 5mg reduction. Definitely nothing in her throat it was just as if her throat was extremely dry.
With her diet that makes sense about leaving some chunks in there for her and luckily I am doing that already. The meat I am feeding her is in chunks. It's only the vegies I have been pureeing. I have been giving her banana in pieces too. I'm pretty sure she has eaten pineapple before, so this might be something also for me to look into. She hasn't to my knowledge really had any problems with fruit before. But you just don't know.
Pep is at the vets today having a joint tap. We got sick of waiting to hear back from the specialist and decided it was the best choice to see if the polyarthritis is still in her joints. We will see how she goes and then look at either Azathioprin or cyclosporine ( they are considering this also).

[Dixie'sMom]

If they give you a choice go with the azathioprine. Cyclosporin can cause mouth soreness and gum bleeding and I'm afraid it may be more uncomfortable for her. :( Of course if she doesn't respond to one, then they will have to keep trying to find one that she responds to. I don't know if they make doggie Cellcept or not, but it has fewer side effects than mos of them. Unfortunately, I didn't respond to it, so we had to discontinue. I'll be watching to see how things go at the vet. Hang in there!

Addendum: They do use Cellcept in dogs. (Generic is cheaper, of course.) Dosing is 20 mg/kg. Its worth asking them about.

[Brooker]

Our vets seem to think that cyclosporine has less side effects but everyone seems to have a differing opinion. It's so hard to know what to do. They have printed me out pages of info to read on both so I can decide. Also as she has allergies the cyclosporine is good to use for them. Our specialist also suggested cyclosporine as the first choice.
Im not sure if humans are more susceptible to certain side effects of the drug making it worse for humans than azathioprine? Or if it is just the differing opinions & personal experiences each person has had with the 2 drugs? I had read info online and to me it seemed cyclosporine was worse. But my vet said that it is more widely used (due to be used for allergies) and hence there is more info on it on the web. The increase in info also leading to there being more info and evidence of its side effects.
Pepper has had cyclosporine before briefly for allergies, but it appeared to make her more itchy and sick in the stomach. We didn't try it for a very long period though and the vets all don't seemed to be too concerned about this. This was a number of years ago now. I was told it was a drug much safer with lots less side effects than pred at the time. I am shocked now at how easily they put her on it back then and how little they warned me about the side effects. As now I have been researching it and the vets have also been telling me 'we don't want to use it unless we have to'.
I will ask our vets about cellcept, hopefully tomorrow. I have not long picked pepper up from her joint tap and urine test. Poor girl she is still fairly drowsy. She hadn't eaten since 8pm last night and I just fed her at 5pm when I picked her up. She must have been starving :(
Hopefully we will have some results tomorrow and then the hard decisions begin.

[Squirt's Mom]

Hi and welcome to you and Pepper! :)

It sounds like you certainly have your hands full! I can't offer much in the way of helping with the meds or her conditions but I can talk herbs with you a bit. Both Milk Thistle and Dandelion belong to a HUGE family of plants called Asteraceae or Composite. So anytime you are looking into herbs for Pep, the first thing you do is look at what family that plant came from - if it is the Asteraceae family, move on along. ;) This is the family that Sunflowers, Asters, Daisy, and thousands of other plants belong to - it is HUGE and lots of herbs come from this family so always look.

One herb you might look into for liver support is Schisandra. Talk to your Holistic vet and see what she thinks about trying this. My Squirt was allergic to MT but could take Schisandra with no problem. I make my own herbal meds for the most part and always have this one on hand. Jerusalem Artichoke is another often used but it is from the Aster family so it is out. I will look in my books and see what else I can find that you can look into for Pepper.

I also wanted to add my support to what Renee said about feeding an ad hoc home made diet - any dog will be better off eating Ole Roy than an unbalanced home made diet - I promise. Tossing in some calcium is nice but not near enough. If the calcium is too much or too little, then other minerals and vitamins will also become unbalanced. If you want a home cooked diet, I STRONGLY recommend you contact someone who can design a diet specifically for Pepper taking into consideration all her health issues, life style, environment, and so on. One I can recommend is Monica Segal.

Nor am I proponent of raw feeding unless it is a last resort - ESPECIALLY in a pup who's immune system is already compromised. I would be extremely hard pressed to feed raw to Pepper. ;) One of mine is on raw but it was the absolute last resort for her - she also has allergies and this was the only thing that helped. So she eats raw but is the only one of 5 that do and the only dog I have ever fed raw. ;) And hopefully the last! :D

I'm glad you found us and will be back if I find anything else you might try for liver support.
Hugs,
Leslie and the gang

[Squirt's Mom]

Oh! I also wanted to tell you how to make the eggshell calcium! Of course cook the eggs themselves in any way you choose. Wash the shells rinsing all the white out but not the membrane, dry them on a paper towel, then bake in the oven at 250' for a few minutes - you don't want them to brown. Once the baked shells are cooled, roll with a rolling pin, glass, etc. until the shells are a very fine powder. Don't leave little chips - made sure it is powdered.

[Renee]

Good call Leslie. Thank you for pointing out that calcium is not nearly enough in the way of vitamins and nutrients. The reason this is the one thing I always hit on though is because it seems to be the last item people think of. It's like they know to add a vitamin, but they forget the calcium. Loss of that alone can cause a lot of damage.

I am not opposed to raw, but given the choice, I prefer to feed a homecooked, rather than a homemade raw diet. Personal choice. :)

[Brooker]

Thanks for all your great info. It's great to find out about the family of plants that dandelion belongs to. We have recently moved house and have been busy removing plants and trees for peppers sake. We didn't have any left at the old place as we felt it was safer. But as her allergies are airborne. We cannot control what the neighbours have in their yards. I will do some research on the family that dandelion belongs to and make sure we have nothing else bad in the yard. Adding herbs/or any plant based things to her scare me the most. As so far her food allergies go they have only ever resulted in her breaking out in bad itches and sometimes little lumps. Clawing at her mouth, scratching ears, chewing feet etc. No trouble breathing or anything (.....yet)
But prior to knowing she had bad reactions to things I put a small amount of cream on her belly to help prevent an itch. It contained tea tree oil and calendula. Within a matter of a few minutes she began panting and turned into the Michelin tyres man. She was barely recognisable she puffed up so much and so fast. Lucky it was in opening hrs and the vet is only a couple of minutes away. I was so scared she was going to stop breathing.
She is also allergic to the antibiotic cephalexin and out of 4 times she has had it, (over a long span of time) exactly 5 days after having she breaks out in hives. Luckily I document everything and keep all receipts for her and I was able to figure out what it was. She now has a massive warning on her file whenever she goes to the local vets to avoid anything similar in make up to cephalexin and be careful with any new drugs. She has been allergy tested 3-4 years ago but I figure they cannot test for everything and also her allergies can change so the results aren't set in stone. It is highly likely she is allergic to more things now and they also didn't test any foods when they do the prick test.

Thanks for your info on preparing the egg shells and advice on the raw food. I think I will start cooking her meat again. The holistic vet I saw never suggested I give her raw, I made that call. But I just do not feel right about changing her to a commercial diet right now. We are looking at weaning her pred and maybe adding cyclosporine or azathioprine in dependent on how her joint tap results come back. So I don't want to add another factor in of a significant diet change. I will look into your suggestions and speek to the holistic vet again now I have some more knowledge. I just feel its not the right timing to be changing her diet so drastically when I have always cooked for her and adding another new factor in when we are changing her medicine. It would be making too many unknown factors and when we change her medicine I want to be sure what her reaction is caused by. Can I get some crushed up beef bones? I will definetely look into tailoring a specific diet for her. Thanks

[Brooker]

Peppers results are back from the joint test and unfortunately the immune mediated polyarthritis is still present :( now we have to decide whether to use azathioprine or cyclosporine. They had to sedate her for the joint tap. She also could have her pred dose in the morning and therefore had to have her morning and night dose all at once when I picked her up. This was yesterday afternoon at about 5pm. She is still very lethargic and not herself and I was hoping by now she would have picked back up. After the anaesthetics had worn off and she was back to her normal pred doses today. I was concern giving her the large dose at once last night and then her Norma dose again this morning would have knocked her about but should have settled by now?
She has only done two very small poos since, which she strained with. However she ate at 8pm the night before the operation and then went all day until 5pm yesterday without food. The poos were runny like soft serve and black in colour. I just remembered the vet telling me the other day about her poos in terms of the liver damage/Cushings. She said as long as they are not black and tarry looking. This is what they look like now after her sedation and joint tap! I am very worried does this mean her liver is damaged? Or could it be temporary due to the overload of pred and anaesthetic and her liver has been working overdrive trying to process them? With your knowledge of Cushings can anyone please help? I am so so worried about her. What signs do I need to look for and be worried about her liver failing.

[My sweet Ginger]

Since I mostly home cook for my pup I liked the eggshell idea as calcium supplement and found this re dosage.

Break the eggshells up into small pieces, and grind them to into a fine powder in a coffee grinder, or put them in a plastic bag and use a rolling pin to grind them. Please note that most food processors or blenders will not grind the eggshell finely enough. A coffee grinder works the best.

Store powdered eggshells in a glass jar with a tight fitting lid. Keep it in a dry place, like a kitchen cabinet.

Dose
If you're using ground egg shells as a calcium supplement for a homemade diet, you will need to add 1/2 tsp. of the powder (this equals about 400 milligrams of adsorbable calcium) for each pound of boneless meat in your recipe.

One whole medium sized eggshell = about one teaspoon of powder, which provides approximately 750 to 800 milligrams of elemental calcium. Elemental amounts are the amounts available for absorption.

[Squirt's Mom]

Black, tarry stools can indicate bleeding so call the vet asap and let them know. Keep us updated!

[Brooker]

Thanks my sweet ginger for your detailed egg shell info. Is much appreciated I will print it out and will be getting myself a coffee grinder.

[Brooker]

I am going to contact the vet this morning when they open. I wanted to wait until Monday to start her on the cyclosporine/azathioprine so that the vets were open in case we had any problems in the initial stages. But due to the symptoms she is showing now I just think we need to start asap, as the sooner we do, the sooner we can reduce the pred and try and relieve the stress on her body from it. I'm just worried that the azathioprine/cyclosporine (I think I am leaning towards cyclosporine) is going to make her feel sick and she is already appearing unwell. I hope she can handle it.i also don't know if they will keep the drugs in stock at our local vet and being a Saturday we may have trouble getting some from another vet/supplier.

[Harley PoMMom]

Are her stools still black and tarry? If so than she needs to be seen by a vet ASAP, that kind of stool is an indicator for internal bleeding.

Please let us know how she is doing, and I hope she is feeling better soon.

Hugs, Lori

[Brooker]

Hi Lori, I just took her outside and she did a poo and it is starting to look more like formed stools again (Only small though), but not soft serve like it was. It also looked more yellowish orange colour. It was dark, as its still very early morning here, and I was using my phone torch to see it. Once it is light I am going to have another look.
Im thinking that it may just be that she was sedated and the double dose of pred maybe put stress on her liver (plus no food for a day) and hopefully she is starting to get on top of it again gradually?? Her poos were fine prior to the sedation/joint tap. She couldn't have internal bleeding from the operation as they were only removing fluid from her joints. Unless she has developed some type of stomach ulcer? Her poo didn't look black under my torch light this morning but I am going to ring the vet as soon as they open. Poor girl hopefully everything is okay, it's just not fair she has to suffer. She is the most beautiful girl and has been so strong with all she has had to deal with.

[Harley PoMMom]

Yellowish orange poop most likely is a gastral issues. Predsisone is pretty hard on the tummy, and it can cause ulcers. I have had to take a cycle of pred for my migraines at many occasions. I only ever once made the mistake of taking pred on an empty stomach, my tummy hurt for a while.

[Brooker]

Thanks for your info. Yes I always give her the pred with food. Since I have been on this forum I have heard you should use a gastro protectant. Neither my vet nor specialist has ever said this to me! I put it to my vet this week and she said that on the 1 1/2 tab a day she is on now it should be fine and we were best not to change anything until we got joint tap results and decided what we were going to do. She has the results now and we have to add another drug (I'm leaning towards cyclosporine) so I am going to ask about the gastro protectant when I go see them this morning.

[Dixie'sMom]

Brooker, I'm still here and following along. I hope the cyclosporin will do the trick for Pepper. I know it's sad for you to see her in pain and feeling so bad.

I'd love to see a picture of her. Click on the User Control Panel (User CP) near the top of the page if you'd like to create a photo album for her and use the Avatar option to set her picture for your posts.

Let us know how things are going when she starts the Cyclosporin. I'm cheering for you both and praying that it is the answer to her troubles.

[Brooker]

Thanks for your support dixie's mum, it's good to know you are still following our story. I have just updated my profile so everyone can see my beautiful girl. I didn't know how to do it, so thanks for explaining for me. I have a new phone so don't have many pics of her on it. Not with her smiling anyway and looking happy. She used to have a full black nose, but being sick has really taken its toll on her and aged her. Her nose is filled with grey hairs now.

[molly muffin]

Well she is just beautiful. :)

What did the vet have to say today?

[Dixie'sMom]

She is beautiful. :)

[Brooker]

Thanks. We think she is beautiful, she has such a gentle nature.

The vet wants to wait until Monday to give the cyclosporine because she is so sensitive. He thinks it will be better to do while the vets are open during the week. Because tomorrow is Sunday and we won't be able to get any help if we need it, if she gets very sick. He also wants to check what dosage to put her on. Even though the cyclosporine takes a while to get in her system he is concerned about leaving her on 1 1/2 pred and adding the cyclosporine as she will be extremely suppressed. He thinks maybe drop the pred back 5mg (half a tablet). I would prefer wait and take the specialists advice, as she has more experience than my local vet with this. But she is so hard to get to return our calls and give advice. We normally have to wait days.

[molly muffin]

That is a shame that the specialist doesn't get back to you more promptly. Does she answer emails by my chance? I have lately found I have good luck with the email option.
I can certainly see him wanting to wait to start her till everyone is there and available.
Hang in there. You are doing great and it is a very difficult situation.

[Squirt's Mom]

What an adorable face! Just wanna kiss it all over!

[Brooker]

Unfortunately our specialist does not respond well to emails either, we have tried that too. I guess since pepper has only seen her once she isn't as dedicated to her as a normal patient she gets to see regularly. I would take her there over our local vet but it's just too far away.
I had been referred to her by a very helpful dermatologist we saw. She works at the same hospital. She had said this specialist was dedicated and a workaholic. I just need to try and get her dedicated to peppers case. The one thing I have found that is very important is sticking with the one vet. It is so hard re explaining her condition and everything that has happened whenever we see someone new. Especially with her detailed history, which scares most people off. My local vet is only just starting to really get to know her. I'm not happy with how hard it is to get a response from our specialist but do t think it would be a good idea having to start again with another one. When we will probably have the same problem. As there is none close by they are all approx 3hrs away and are all going to be extremely busy due to the lack of specialists available in this area. I really wish there was a specialist closer as if I made an appointment and took pepper there she would have to give me answers and get back to me.

I know 'squirts mum', she is so smoochable :)

[Brooker]

Hello,
So we have finally started pepper on cyclosporine. We started her last Wednesday but only on a half dose for a week. So far she hasn't been vomitting or appearing too unwell from the cyclosporine. She has started displaying the pot belly bloating again today and her alp levels are back in the 2000 + again. I had the vet run testing to check her liver, gall bladder and pancreas Last Thursday and they said she was okay. She did have blood in her wee so they have sent away to the lab for processing. We want to try and get her to last as long as she can on the 1 1/2 pred tablets she is still having and the cyclosporine, to give the cyclosporine enough time to get in her system. As I do don't want her to have a relapse of her impa. We missed our chance with getting it under control with just the pred and I do not want that to happen with the cyclosporine. There seems to be a bit of differing opinion as to how long exactly it will take to get in her system. I heard 10 days to kick in and up to 28 days until full effect. I do not want to put her through too much and damage her body giving her both. But want to try give her a good chance at beating the impa. What signs should I be looking for to signify that we should start reducing the pred? She isn't having any accidents in the house or drinking and peeing excessively like she was at one point a while back. But she does have the belly back and slouched back, depressed and really hungry. Her skin looks thin again too.

[Dixie'sMom]

I'm glad Pepper has started the Cyclo and seems to be tolerating it well, even tho she appears to not feel very good. Hopefully that will change soon.

The Prednisone taper should depend on Pepper's clinical signs and test results. I'm not sure what all they do except for the joint fluid test to determine how she is doing. Do they do an ANA or RA factor to check her levels, or another specialized blood test to see how well she is doing? Or do they just depend on your report of her condition?

For example, In my case, if I am the same or better than my last visit according to my test results and their examination, they make no changes to my meds. If I am worse, they make a change.

Based on what I know of immunosupression in humans, it sometimes takes 4-6 months to get full benefit. This may be less in canines since they are smaller and their metabolism is probably different.

Long story short - taper the Prednisone on a schedule that your vets determine based on clinical tests and examination in order to avoid a flare. What are they saying about the Prednisone right now and do they have a plan to taper in the future? If they haven't mentioned it to you, then ask.

Don't worry about Pepper's physical Cushing's symptoms, potbelly etc. Those are not life threatening and although they disturb you, they are not as important as getting her autoimmune disease stabilized. There's plenty of time to work on the Cushing's symptoms later.

Hang in there! You're doing great. :)

[Brooker]

We did a joint tap a couple of weeks ago (maybe 3 actually now) and she still had the impa in her back knees. The number of abnormal cells had decreased though and they were all but gone and back to normal cells in the other joints tested. They so far have only done a pancreatic lipase test to assess how her pancreas' is functioning, an ultrasound of gallbladder (checking for sludge in there), and checked her bloods i.e alp, alt etc. all appear to be normal (under the circumstances). Her alp was up greatly, but they are telling me this is to be expected with the steroids and her alt levels were okay and they do not seem to think her liver or kidneys are in a bad way based on the levels. I haven't heard our vet mention ANA or RA tests.

The plan is to wean her as soon as we can, maybe starting this week or next. We wanted to try get to a week or 10days with the cyclosporine to hopefully get it in her system as much as possible. A week will be this Wednesday.
A lot of the judgement seems to be how I am reporting her condition. She is more down now than she was, but they found blood in her wee on thursday. This has been sent away for analysis and she is not taking any antibiotics yet. So I cannot say whether she is feeling worse due to the pred or a urine infection or if not that the vet said maybe the blood was from something else I'm not certain what ? I thought she had said kidneys being bypassed/blocked somehow? She didn't really go into detail, I guess because it would more commonly just be a urine infection and she probably didn't want to alarm me to anything else. The urine test results will be back today so we will have a better idea then. There are certain antibiotics that can trigger impa (auto immune diseases) and also pepper is allergic to the antibiotic cephalexin so she cannot have any antibiotics related to its make up. This is why they wanted to wait for a conclusive urine test result and to find out the strain of infection so we can pick an appropriate antibiotic taking into account all the limitations. I guess if it is just a urine infection and we get her on antibiotics then I can see if that perks her up. We can assess her condition better once we rule out that factor. I hate having to put another drug into her though, but if it has to happen we have to do it.
Wow up 4-6months for full immune suppression in humans, that is a long time. It must be terrible :( I'm struggling with the thought of 10days for her.

[Harley PoMMom]

Just wanted you to know that you and sweet Pepper are in my thoughts and prayers, I do so hope that the cyclosporine will work for her.

Hugs to you both, Lori

[Robert]

I feel for you. One of my dogs had autoimmune disease except it was a blood one. She too was on pred and was still on it when she passed. She passed from a heart condition not the autoimmune illness. But remember clearly the ups and downs and stress with the autoimmune illness. My thoughts and prayers are with you and your bub.

[Brooker]

Thanks everyone for your support. I know you have probably all been through similar situations. It has been such an emotional roller coaster since peppers diagnosis at Christmas. It has been extremely mentally, physically and financially draining. Lack of sleep due to researching anything I can to find out how to help her and not being able to turn my brain off. Even dreaming about things that could be of importance to help her. I think I am going crazy, but I am not going to give up hope on her.

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 and very sluggish. She is still very down and is looking pot bellied and slouched in her back, plus the increased drinking. She had a very slow recovery after she was sedated for the joint tap with pamlin (diazepam) but I didn't notice so much her being unsteady on her feet. Probably because I expected her to be unsteady anyway due to be sedated. 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 -taken while on cyclosporine & pred & diazepam- only on pred when taken) and with time after the drug was withdrawn ( a day or 2) 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 or clutching at straws 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 recovery was last time :(

[Squirt's Mom]

Just wanted to pop in and let you know our thoughts and prayers are with you. I know that obsessiveness when we must, absolutely must, learn all we can in order to help. Peppers is very lucky to have you.

[Dixie'sMom]

Ok... the first thing I want you to do is take a few big, deep breaths. You have got to relax some for Pepper's sake. She will be able to sense your anxiety and it will make her anxious also. Big...deep... breaths.

For now, stop the research. Pepper's situation is complex and you don't have enough information yet to know what you are dealing with, so the research is just one more thing to worry about and for your mind to obsess over. You will get some answers Wednesday about the state of her kidneys and the possible source of the blood. Once you get some answers, then you can go back to researching with a renewed sense of purpose.

I admire your dedication to Pepper and understand your need for information in order to formulate a good plan. And I know how much she means to you and how much you love her. Please take good care of yourself because Pepper needs you to be healthy, rested and strong. Take some Tylenol pm at night to sleep if you need to, or a nice big shot of liquor. You have to relax a little and I know that is so hard to do when you are so worried about her.

If you need to do something, then write your questions down for the vet who is doing her tests Wednesday. Should the Cyclo be stopped? Should the Prednisone be tapered quickly? Does she need painkillers or additional meds? Can her kidney's and liver handle the workload of filtering the Cyclo and Prednisone from her body? etc. I'm sure you have your own questions.

We're here for you and praying for you and your baby. Hang in there.

[Harley PoMMom]

It sounds like the test used to check the protein loss was an UPC (urine protein:creatinine ratio) test, right? There are many, many things that can make that test have elevated results; any inflammatory conditions in the urinary tract will increase protein loss.

Protein loss is common in dogs with Cushing's and therefore a dog that has been on a steroid, such as prednisone, for a period of time can also lose protein through their urine. So maybe Pepper's UPC results are falsely elevated.

Hugs, Lori

[Brooker]

Thank you for your kind thoughts and advice, I have only just read your replies. I ended up coming to the same conclusion and stopped researching yesterday and have tried to take a step back and stay away from the computer and be calm for Pepper. As she is a very perceptive dog and I do not want to put extra stress on her. 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 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. 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.

The protein test was added to the lab on Friday when no interim growth had been reported yet. So I have not paid for the test yet and do not have an invoice with the name of it listed. But I'm almost certain that was what it was called.
When I had a better chat with our vet yesterday morning she was talking about an 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 this 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.
I didn't realise protein loss was common in dogs with Cushings.
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.

[Robert]

Praying for the best possible results today. Noticed you are in Australia. Me too- if you ever want a chat bout anything or just someone to listen let me know- have unlimited calls. Cheers.

[molly muffin]

I think it depends on how the dog acts once they take them back for the ultrasound. Molly doesn't get sedated for ultrasounds and never has been. So I know it is possible.

Also, if there is a urine infection or a gastro intestinal problem, we have noticed that UPC's go up and you want to wait a couple weeks and then do the Urine protein test.

Glad you are taking some time to relax.

[Dixie'sMom]

I'm so glad that you and I were on the same page. :) Great minds work together, right?

Like Sharlene's Molly, my Dixie doesn't have to be sedated either, so hopefully Pepper will let them do the ultrasound without any heavy sedation. Good call on your part to get your vet to advise them not to give her the Valium.

I get confused about the days with my southern US time and your time, so if Pepper's ultrasound is today, then I will be praying and crossing fingers and toes and Dixie and Button's paws for a good outcome. I want this little girl to get to feeling better and after today hopefully we all will know how to help her.

Hang in there... you are doing great! :)

[Squirt's Mom]

How did the US go?

[Dixie'sMom]

Waiting anxiously for Pepper's ultrasound report. Hugs to you both.

[Brooker]

Peppers results from her ultrasound are back and they are great (in terms of what could have been)! The only signs of anything different than normal were an enlarged liver. Which is to be expected with chronic prednisone use. Other than that she also had an enlarged spleen. But they think this 'not pathologic with Pepper'. They have just said to keep an eye on it and if it became a worry they could do a fine needle aspirate.

The specialist said to disregard the urine test and that we could not believe it to be accurate until she was off the pred in terms of the high protein levels.

I tried convincing them not to sedate her but they would not come at it but agreed only to us the light s sedative my vet had mention that only had a short lifespan in the body. She was quiet unsteady on her feet when we picked her up until she went to bed. She also was spaced out looking at the wall. But the specialist told us that she would be doing this until the following day. She did a poo before bed and it was solid and normal. She had diarrhoea after the joint tap sedation. The specialist looked into the dosing of drugs that pepper been given for her joint tap and said that she had been given a hefty dose. She said she wouldn't give a dog of peppers size such the high doses she was given. I only had one drug written on my invoice that they had given her but in peppers records it had listed 2 or 3 and she had been given high doses of all of them. She said she wasn't at all surprised that pepper was quite knocked about by it!
It's only before 7am in the morning here now and pep has got up and walked around a bit wanting breakfast and so far she appears okay.


Even though we have been trying all this time to get info from the specialist through our vet she did not seem to be very familar with peppers case. She was very concerned at the pred dose pep is still on and how long she has been on it for. She said 'you are going to kill her if you continue on this path'.& she said she 'had never had a dog on that dose for this amount of time (3months), except maybe ones with a brain cancer'. It makes me feel sick hearing her say that, when all along I have been desperate to get her off them but we have been waiting for our vet to get a response back from the specialist in regards to what to do. Weeks went passed after the joint tap with me hounding them daily to get an answer. The specialist had told me I couldn't ring her directly. I just don't know what else I could have done. I hope I haven't permanent damaged her.... I feel so terrible.
I guess I should have taken her back to sydney to see the specialist to get an answer. As it seems that was the only way we were going to get one.

She said that in a breed such as peppers (staffy) she does not think it would be uncommon for the abnormal cell levels in her knees to just be arthritis and possibly not impa. She has told us to cut her pred dose back and contine the cyclosporine but maybe increase the cyclosporine now up to a full dose. She thinks a blood test now to check the cyclosporine levels would be a good idea to be sure of its affect in her body. She feels peppers impa is under control and the only way we are truely going to know is to get her off the pred. Regardless of whether she is going to relapse, she said she needs to get off the pred before she has too much muscle loss. Which in her breed is going to leave her joints even more exposed to damage and limping.

I feel relieved the day is over and we got the result that we did (nothing bad found in the realm of possibilities facing us) but I am feeling absolutely awful about the specialists comments about peppers pred (over) dosage and worried now about the long term affects.

Thanks everyone for your support. I had managed to get myself settled and was calm on the day, which I think helped pepper.

[molly muffin]

Oh my goodness. Did you tell the specialist you have been asking about the pred for a long time due to your own concerns and your vet was waiting for the specialist to advise. Grrrrr

I know in our case too, it seems like the ones with the most knowledge is the specialist and that I have to go to them to get quicker test results and a comprehensive analysis of molly's over all care. It can be so frustrating, but I really do think this specialist is someone you are going to want to see on a semi regular basis at least till you get control of everything.

Over all it sounds like a good report though. So lets see where we end up at. You're definitely on the right track and Pepper is quite complicated.

Hang in there!
Hugs

[Dixie'sMom]

I'm not sure about the enlarged spleen but I do know that enlarged liver is common in Cushing's pups. Hopefully that will go away when the Prednisone is stopped. So all in all it sounds like nothing horrible was found so that is a true blessing and I know you are relieved!

I agree with Sharlene. I think you are going to have to have more contact with the specialist in order to stay on top of Pepper's health. Although your regular vets appear to have done a good job with Pepper, I think her condition may be too tricky for them to be able to manage effectively. I hate this because of the lack of response you get from the specialist. Is the new specialist who did the ultrasound and advised you available for you to use on a semi-regular basis? Or is this the same specialist that wouldn't get back to you? I'm confused.

It great to see that your instincts have been correct all along regarding the Prednisone. You are very in tune to your baby girl and she is so lucky to have you!

Keep us posted on the next steps. Go Pepper!

[Brooker]

The ultrasound on pepper was done by a specialist sonographer, she works at the same place as peppers internal medicine specialist who is the one we have been dealing with for the impa (the one who doesn't get back to us). We didn't actually get to talk to the sonographer. Peppers impa specialist went through the results with us. I was quite annoyed and upset with the specialists comments that I was going to kill her with the pred. I have been calling my vet daily and hounding as much as I could (so much so that I think they think I am a bit crazy) to get them to try get an answer from our specialist. The specialist told me I could not call her myself otherwise I would have been doing so.
I didnt feel like I could say too much that may offend her in terms of pepper being on the pred for so long only because she wouldn't get back to us.
I just hope pepper is strong enough to pull through this next period while we decrease the pred and increase the cyclosporine. She has just started to look weak. I can now notice her muscles wasting away and her becoming weaker on her feet. The specialist is concerned that she needs to try and not loose anymore muscle as she with her stocky build she needs the muscles to support her joints and prevent injury. Has anyone else experienced their dogs beginning to show muscle wasting? Can they recover from this and does it take a long time to get their condition back? I'm so worried that I have destroyed her body :( Is there anything I can do to help her. I am not letting her run around (not that she does hardly at all) and I am not letting her jump up and down from chairs, the car or bed. I am just lifting her to try avoid any extra stress or injury to her joints. I know it's going to be a slow process it's excruciating thinking how long it's going to air to try get her of the pred and back in good condition and then worrying about what other problems the pred has caused that we are going to see as she weans off :(

[molly muffin]

Any place around that she can get some gentle water therapy? swimming easily, or walking on a treadmill in the water. They have specific ones for dogs. If not, then walking and incorporate some small raised areas so it pushes the muscles to build. It does take time though.

I had a dog on Pred for 8 years. It isn't good for them and caused her to have cushings caused by the pred, introgenic cushings. She had the worst allergies I've ever seen in a dog and had multiple surgeries for hematomas on her ears due to the allergies. Every time I'd try to taper her down it would just get worse. She swam and she walked and ran and played till not long before we had to let her go at age 10.

I say that because 3 months while not optimal of course, no one wants them on it longer than necessary, as you didn't, but I don't think it will a death sentence and that isn't a very nice thing for that vet to say, when if their practice was answering the vets questions in a responsible amount of time, she would have been weaned down long ago. I blame them for the length of time, but like I said, it isn't going to kill her. I've definitely seen other dogs on it longer.

Hang in there.

[Brooker]

I do think there is a place nearby that has hydrotherapy. My only thoughts are that with Pep's immune condition and seeming that her immune system is being suppressed at the moment, she is at greater risk of infection. Maybe swimming in water where other dogs have been may put her at risk of getting an infection? I know they say not to take her to parks with other dogs, so I'm thinking swimming in a dog pool may be risky too?
We live on an acre so maybe I will just take her on slow walks around our place each day and on some small raised areas like you say.

I'm sorry to hear about your dog. Allergies are the pits. Pepper was quite bad when she was around 3-4, from grasses/weeds etc. She would drag her belly down the rocks/concrete ramp at the back of our place until she was bleeding. Hers have been changing over the years. At one point her feet were really bad and we had to make her wear shoes to stop her chewing them and protect her feet from the grass, which appeared to make her feet worse. Then she got really bad around her neck coming out in big red welts. She has also had times where her mouth and ears were really bad (scabby and bleeding) but that is food related for her. We have been lucky though as we have managed to find ways to control her allergies to an extent and have only needed to put her on the pred every now and then when she got too bad and got infections. We have had to be very strict with her in order to maintain control over her allergies. Baths every 3 -5 days, applying oatmeal conditioner regularly to her to form a protective barrier against grasses, wiping her done after she has been on the grass, cleaning in her feet regularly and applying cortisone spray to them, cleaning her ears regulary. Making sure the grass is kept low and she is not allowed on it after mowing for an hr or so. Removing the majority of plants from the yard and making sure weeds are kept away. Making sure no one gives her any different food as there is quiet a lot that play up with her and keeping all creams and cleaning products with tea tree oil in them far away from her. It has at times almost been a full time job of preventative measures to keep her allergies at bay. Luckily I work from home so it has been possible to look after her like this, although it's hard to get work done. She hasn't been as bad the last few years in terms of the grass allergies, so I haven't had put shoes on her or go to the extremes we once did listing above.
Your poor girl having to have multiple surgeries, pepper has never been that bad. It must have been terrible, but sounds like she was still a happy dog, running around and swimming.
Yes I am quite frustrated with the specialist, but I have decided I need to stop worrying about it. What's done is done and I need to move on and just focus on getting pepper better now.

Ps does anyone have experience with the inside of heir dogs ears going red and hot for a few hours or less and then going back to normal? I have noticed peppers ears do it after her joint tap, again after she had famotidine and after her ultrasound sedation. One ear did is again this morning, normally it has been both. The morning after her ultrasound both ears did it for a few hours and then went back to normal. I may just be being too picky. But thought worth mentioning in case it means something?

[Brooker]

Hi, I was just wanting to see if anyone had any recommendations from experience of good places to have a personalised diet plan made. I have just had one done with pet diets (which was quiet expensive) but i do not feel satisfied that it is truely personalised to my girl. They have listed her food intolerances and atopy as areas the diet was specific to. But don't appear to have paid any attention to her current state of health as requested. Pepper was diagnosed with impa at Christmas and has been on high doses of steroids since. We were having trouble getting advice from our specialist and so she has been on the high doses longer than normal without the usual weaning. She developed iatrogenic Cushings and now also has muscle wastage from the pred. I wanted a diet plan that took into account the effects of the pred as well as catering for her existing allergies/intolerances. They don't appear to have made efforts to help cater for her current steroid induced state.
Does anyone have any recommendations of good places?
Thanks in advance

[Harley PoMMom]

Monica Segal is one nutritionist I would recommend, she has formulated diets for my dogs and I was pleased with her service, her website: http://www.monicasegal.com/

Hugs, Lori

[Brooker]

Thanks Lori I will check her out :)

[Squirt's Mom]

I second Monica. ;)

Dr. Jean Dodds is worth talking to as well.

Before you choose someone to help you with this, come let us know who are considering and it's possible we can offer some insight.

Based on my own experience and the experiences of several others I know, avoid UC Davis. Their diets are not individualized.

[Dixie'sMom]

I can't help with the diet but wanted to say Hi to you and Pepper. How is she doing? Any progress on the steroid weaning?

[Brooker]

Thank you. Pepper was going well on the pred weaning but she over exerted herself on Monday and then again on Tuesday and has now begun limping. We got results back from her cyclosporine blood level test yesterday and her body is not absorbing it well. We expected her to be at immunosuppressant levels but she is way under. So we need to up her dose. We had just reduced her pred back to 10mg every second day. But have had to go back up to 20mg every second day because the cyclosporine is not suppressing her immune system and we are worried the impa may come back. Especially now she is limping. But I am preying that this is just due to the overexersion. She had some acupuncture and chiro/massage yesterday and last night was limping worse. She also started drinking more. I'm not sure if this is normal after the acupuncture and massage/chiro?

[judymaggie]

Hi! Found this as a possible after-effect of canine acupuncture:


Rebound Effect: This is the worsening of symptoms for up to 72 hours following a treatment, followed by improvement. This is unusual and probably occurs in less than 5% of all patients. This usually is taken to be a good sign, however, because these individuals often do very well following the rebound.

My Abbie's first acupuncture appointment is next Tuesday so can't speak from experience with dogs but I have had several periods of acupuncture treatments. I often did feel worse after a treatment but, as the treatments continued, the time frame of feeling worse was reduced until I felt good for the entire time in between sessions.

[molly muffin]

Oh poor Pepper. So hard to get things to balance just right sometimes. I know you didn't want to have to increase the dose of pred, but not a lot of choice it seems for the moment.

Hope she is feeling better and not limping soon.

[Brooker]

So far today pepper hasn't been limping. She still appears a bit sore but isn't showing the limp.

I know the vet mentioned one of the acupuncture points that she used was for the liver. Not sure whether this could also account for increased thirst. Or i guess probably just the increase in pred?

Yes I did come across that quote about the rebound effect when I was searching the net. Hopefully that's all it was.
She does seem (so far) much better today. However I caught her straining to do a poo. But we also increased her cyclosporine today and I know that can cause gastro upsets. So maybe that caused the change and straining?

[Brooker]

More bad news for pepper :(
Her blood test is back and her alt level (prior to now her alt was always okay it was only her alp that was up) has increased to the borderline of permanent irreversible liver damage. It is 3x4 times normal levels. I am taking her in for another blood test tomorrow morning and stopping all pred. Our vet seems to think she will cope with stopping the pred considering she was down to an every second day dose for the past week and a bit. She is more concerned that her iatrogenic cushings may have become full blown cushings.
We tested her blood prior to starting cyclosporine and her alt level was fine but now it has gone up for the first time. Her blood level of cyclosporine is extremely low though so our vet doesn't seem to think this could have increased her alt. Perhaps combined with the pred it has? By stopping the pred and considering the cyclosporine levels in her body are well below immune suppressant levels we risk an impa relapse. But there is no other option, I do not want her liver to reach the point of no return.
The one positive to come from today is she has not limping.
She is still hungry and wanting to eat all the time and has no sign of vomiting which the vet said was good in terms of her livers state.
Surely we are going to have to get a break with her soon, it's been such a stressful roller coaster of a battle. I'm starting to feel like we are fighting a loosing battle though. Everywhere we turn we seem to hit a brick wall. But I am not going to give up, she deserves to get better, she is such a beautiful spirited dog.

[molly muffin]

Oh no! I hope the blood test tomorrow brings better news.
It's good she isn't limping at least. Crossing fingers for beautiful Pepper!!

hugs

[Dixie'sMom]

Oh goodness. Poor Pepper. Yes, you both very much need to catch a break. I'm sending prayers of healing and mercy your way. Hang in there!

[Brooker]

So we did another blood test yesterday and peps results were higher than before. I had a freak out over night prior to the blood test and decided I wanted to get the specialists opinion on her results before changing her meds. She sees dogs in peppers situation all the time so maybe the figures would not be as bad as my vet was saying.

The specialist had told me not to ring her directly, but my normal vet wasn't going to be back until Monday and our vet never could get a response from her. So I knew I was going to get in trouble ringing, but when faced with possible permanent liver damage (as per what my vet had told me) I decided that was more important.

Well... I got absolutely blasted by the specialist for ringing, I haven't been spoken too so rudely before. I know she is a busy person, but I am only concerned about my girl. Is that so bad? It's the only time I've rang her, it's not like I am ringing her everyday.
After she blasted me, she rang back a couple of hours later more calm and said that peppers results were nothing that she could see to be conerned about. She said they were consistent with what she normally sees for dogs on the drugs that she is on. She said that you cannot pay too much attention to the alp and alt s etc when on the preds. My worry is if you don't pay attention how do you know when you are approaching permanent liver damage?

She has told me to continue weaning the pred and start upping her cyclosporine. I am still very worried, but I guess I have to trust her and do what she says otherwise she will stop helping us.
She has said that we may be able to start having phone consults and just get the tests run at my vet. So I don't get conflicting advice. I am happy with this but don't want to annoy my vet and still want them in the loop in case we have trouble.

My vet was worried that she has developed full blown Cushings. I guess we won't know until she is off the pred. The specialist didn't mention it.

There has been no more limping and she is not down at all. She has a very dry mouth though. You can hear her tongue grinding in her mouth sometimes. She has been sleeping deep at night and snoring louder than normal. But otherwise she seems fine.

I am very worried that my poor vet is going to get blasted on Monday (I know all too well how that feels) from the specialist for frightening me. She has been so good to us and I feel so bad for getting her in trouble. She doesn't see dogs on the drugs Pepper is on everyday, like the specialist does and was only looking out for Pepper. I hope she doesn't loose trust and focus in me after this. We need someone here close by in our corner.

[molly muffin]

Well I think that is a horrible way for a specialist to respond. Even if normally she doesn't take calls. Sheeeezz. Does she respond to emails?

I would simply call your vet on Monday and tell her you called the specialist and why and that you don't want her to get yelled at since you already where. But you got worried and scarred. I'd hope your vet would be understanding. Talk to her about working out a plan and for the phone consults with the specialist but that you don't want her cut out. Just be straight forward and she won't be caught unaware.

Hang in there. It is a tough situation but you are handling it well. You are doing everything for pepper. That is what counts.

Hugs

[Brooker]

Thanks. Yes I was thinking I should call on Monday and warn her. :(

[molly muffin]

I think you will feel better if you do. :).

It'll be okay. Hugs

[Brooker]

Pepper had started sleeping more since upping the cyclosporine. Now today she was sleeping lots and now isn't following me around as she normally does. She is very lethargic and having trouble getting up, a bit slow and unsteady. She is unwilling to jump up and has some gas. She has her sad face on again with head down and sunken back. I originally thought it was something associated with the cyclosporine because she has been getting worse the more that I give her. Now I'm panicking that she is relapsing. But I just had a thought whether it could be full blown Cushings? My vet was afraid that she may have developed it when I talked to her on Friday after the test results came back with the elevated alt alps etc. Are the above symptoms of Cushings? Could the increased cyclosporine have pushed her over. She is not wanting to drink anything though? So worried again :(
Don't know if I should keep giving her the cyclosporine. It's Sunday here now.

[Dixie'sMom]

Is there ANY other specialist besides the one you have for Pepper? I just can't imagine having to deal with that rude and crude hateful woman. Are you sure there are no other choices?? :(

Pepper obviously isn't feeling good. Stopping the steroids suddenly isn't a good idea so I'm actually glad you have resumed them and will continue to wean her. As for the cyclo, I don't think I would increase it as long as she is feeling so bad. I think I had mentioned the mouth symptoms as a side effect so don't be surprised if her gums start bleeding. If that happens and she stops eating, you will have to stop it and try another immunosuppressant. I would only increase the dose when she acts like she can tolerate a higher dose and I would stop all together if she doesn't adjust to it fairly soon.

I am no vet so my thoughts are only as a mother of a beloved pup and what I would do if it were my dog. This has to be done in a way to maintain some kind of quality of life for Pepper, otherwise its not going to help anything.

You are in such a tough position. I'm still sending prayers and hoping someone will be put in your path than can truly work with you and help you with Pepper. Hang in there.

[Squirt's Mom]

How is Pepper this morning?

[Brooker]

There would be other specialists available, but they are all also in Sydney as well, so still 3hrs away. I have considered finding another over and over, but I keep coming to the conclusion that it is better to stay where we are because she knows all peppers history now. If I take her somewhere else we will have to start all over again. She also inspected pepper a month into the pred and again recently so she has seen how pepper has changed with the drugs. A new specialist wouldn't be able to compare her physically to what she was a few months back.
I will have to try and toughen up and learn to deal with this one I think. If I start having phone consults perhaps she will become nicer with more contact.

I do remember you mentioning the bleeding gums. Hopefully it doesn't come to that :(
Pepper improved at 4pm yesterday and was more back to normal. I gave her only 1x50mg cyclo last night and she got a bit sleepy again. It's now morning and I am about to get up and see how she is whe we get up. I have to give her 2x50mg cyclosporines this morning and 10mg pred and then I'll see how she goes after that.
I had also given her denosyl for the first time on Saturday and Sunday, but surely that couldn't make her like she was. I am going to try not giving any to her today just in case and see if there is any difference.

The side effects of cyclosporine are supposed to be vomitting, but perhaps pepper doesn't actually vomit she just gets the sick feeling and feels so terrible and that's why she is sleeping and hesitant to move with her sad face? She had one (50mg) at 12 Saturday and then 2tablets (total 100mg) sat night and then two again Sunday morning. So this was the most she has had. We are back to 2 morning and 1 night now for the next week. So she may be okay until she gets the 2 morning and 2 night which we are supposed to start the following week.
Thanks for all your support, it really helps, I will keep you all updated on how she is this morning after more meds. If she is worse I will be trying to book a phone consult with the specialist asap.

[judymaggie]

Just a thought -- if you think the cyclosporine is making her feel bad, maybe try giving her pepcid ac 15-20 minutes before she eats.

[Dixie'sMom]

Good idea Judy. Prednisone is hard on the stomach anyway and with the addition of the Cyclo, she may really have a belly ache. It wouldn't hurt to try it.

[Brooker]

Pepper was weak in her back legs last night and had trouble getting up. I took her to the vet this morning and they monitored her for the day. She had been a bit weak the previous day but not as bad. I was concerned she may have relapsed (however it was different than previously when she had relapsed). Other wise I didn't know why she was looking weak in the back end and hadn't heard that cyclosporine could do that. The vet has assessed her and doesn't believe that she is relapsing. We have came to the conclusion that she now has arthritis in her back knees. The last joint tap showed increased abnormal cells here that the specialist seemed to think we're just normal arthritis. Now that we have reduced the pred down to 10mg every second day the arthritis is showing. This may be adding to her feeling bad combined with the cyclosporine. She had some more acupuncture and remedial massage today. Our vet wants to give her tramadol, but mentioned concern of triggering the impa. We have decided to not make any decisions until after the Easter long weekend, just in case I have problems with her. I would prefer to try and manage it without adding more drugs in, especially if the vet is concerned about possibly triggering her impa.
Does anyone have any recommendations of arthritis treatment? With all the drugs pep has been on I would like to try and manage it without drugs if possible.
So it's been a stressful few days and not ideal that Pep now has added normal arthritis into her list of problems. But it's better than what it could have been. She hasn't been as gassy from the cyclosporine so hopefully she may start stabilising on it and feeling better. I had a good chat today with our vet about pep and where we were heading and feel okay at this point. Our vet had had a good chat on Monday with the specialist too and we have sorted out all those problems and appear to now be on the same page.
Fingers crossed we can stablise her for a while and not have anymore problems arise.
We tried pep with the gastroprotectant famotidine before and she seemed to have a bad time after having it. We are not certain if this caused it but decided best to just stop using. We looked into other gastroprotectants but they all take the cp450 enzyme path through the body (the same path as cyclosporine). They either increase or decrease levels which makes things a bit difficult. I have been always giving the cyclosporine with food so that may help make it not as harsh on her stomach.

[Brooker]

With regards to the bleeding gums. Is it the dry mouth that causes this? Is there anyway to help make her mouth not so dry? She has never been a big drinker (except when on the pred). Now we have reduced the pred she is back to normal drinking. Normal for her is only really after meals and if she has a run around (which I am trying to minimise too much excercise at this point ). I would hate for her to get bleeding gums

[Dixie'sMom]

You know, I'm not really sure if its the dry mouth that leads to the bleeding gums or just the tendency for the cyclo to cause mouth ulcers.

I know they make glycerin mouth swabs for humans for mouth issues so I would think it would be fine to use on Pepper to keep the mouth moist. Unfortunately, I don't know where to get them from. I guess maybe your pharmacist would know? They look like little pink sponges on a stick. If all else failed some of the moisturizing mouth wash swabbed with a small sponge could help. Hopefully the dry mouth will be as far as it goes and she won't have any bleeding or ulceration.

Hang in there!

[Brooker]

Thanks for the info. I may ask my vet next time I'm there about the possibility of mouth ulcers and see what she says. Ill see if she thinks it may be worth taking any preventative measures now or wait and see how pep goes. It's better to be prepared, but hopefully I wont need to be.

[Harley PoMMom]

My Harley eventually became nauseated with famotidine, I switched him to slippery elm bark (SEB) and this did help...here's a link about it: http://www.littlebigcat.com/health/slippery-elm/ One word of caution with SEB, you need to give it a couple of hours away from other medications as it may interfere with absorption.

Hugs, Lori

[Brooker]

The (human) herbalist I have seen about pepper initially recommended slippery elm and a few other natural things that help when we were faced with starting the cyclosporine, but we decided to best not add anything at that point until we had started the cyclosporine. So we knew if she showed any reaction what it was to. I may look into this again now. Thanks :)

[SasAndYunah]

I have been following your thread silently..reading only :) But today I saw you mentioning that you give the Cyclosporine with food in hopes it helps prevent Pepper becoming nauseous? But to the best of my knowledge, Cyclosporine should especially be given on an empty stomach in order to prevent nausea and stomach upset. At least one hour before feeding or at least 2 hours after feeding. So this might be why Pepper is not feeling that well...? Apart of course from the artritis.

All our best to you and Pepper,

Saskia and Quincy :)

[Brooker]

They told me some dogs do better with food and some without food? But said it may be better on peppers stomach with food because she was also having pred too and with food. The absorption rate isn't supposed to be as good with food though. But my specialist said we would be better to stay consistent and keep giving with food so that when we test her cyclosporine blood levels again it was based on the same situation (with food both times).
Today she seemed better however, I can see her arthritis pain now. She is hesitant and slow getting up in her back legs.

[SasAndYunah]

Indeed, absorption is negatively affected when taken with food... "Pharmacokinetic studies have been performed in the dog and it has been determined that bile is essential for absorption after oral administration of cyclosporine. Hence, it should be given on an empty stomach". So yes, bloodlevels would be different but on the other hand, you'll reach therapeutic levels sooner (with a lower dose) when you give it on an empty stomach. So I'm a bit confused as to why a vet/specialist would not recommend giving the cyclosporine on an empty stomach. But hey, it's the way it is, isn't it? :)

Glad Pepper seemed to be doing better today but sorry to hear her arthitis is playing up more now...

All our best,

Saskia and Quincy :)

[Harley PoMMom]

I am thinking the reason it may be better for Pepper to have the cyclosporine with food is because it may upset her tummy, and if this would cause her to vomit than the cyclosporine wouldn't be getting into her at all, better a little than none at all.