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Hi Amy,
I’m sorry you have had so much difficulty, especially with travel and the up and downs with the treatment. Is your boy a Bernese Mountain Dog?
My first comment is that you should be very cautious about decreasing either the cyclosporine or the prednisone this much with only a PCV HCT of 30%. That’s still right on the edge of high range moderate anemia range. While the prednisone has very severe side effects, the side effects of cyclosporine are minimal, usually gastrointestinal.
Perhaps you could describe to me in more detail what all your medications are, how they have been dosed up to now, when you give them and your boy’s weight. The cyclosporine is very helpful in taking on a role in the immunosuppression of the immune system but it’s only been, my count, only a month since you started treatment, it needs a bit longer to really work properly.
The main reason we suggest owners allow their vets to decrease prednisone rapidly is if there is a health condition that is urgent and directly due to the prednisone. Very few dogs develop iatrogenic (caused by the meds) diabetes but those that do need a more rapid reduction of prednisone.
We have seen a number of dogs relapse when the prednisone is decreased too much, too soon before the dog has reached about 36% HCT PCV. This is the lowest normal value for a dog.
The antibiotics are very tricky, if he has a specific infection that they have identified, e. coli, they can often treat more effectively if they use a targeted antibiotic rather than a broad range antibiotic.
The drug you mentioned to treat for a possible tick disease is doxycycline. It can be a very harsh drug to the stomach along with the prednisone. The two of these drugs together can lead to stomach ulcers if the vet didn’t prescribe an antacid. Dogs have very acidic stomach acid and can develop ulcers very quickly. We recommend even something basic like generic pepcid, given 30 min before a meal. Large dogs like yours might benefit from a second dose for their second meal of the day.
Once a stomach ulcer(s) develops it can be very painful and in some cases that are serious it can lead to internal bleeding. I am guessing that the discomfort he is having is because of an ulcer(s). This is one thing we can’t test for very easily. It would be very invasive and difficult for your dog to be tested so we just assume that he probably needs to be protected from ulcers and to treat any possible ulcer that may develop. I have a vivid memory of a dog I helped the owner with many years ago. This lovely little dog was in so much pain from ulcers that it ate a number of socks to stop the pain. This little thing did not survive after they tried to remove them surgically. I tell this because I didn’t know at the time about ulcers like this and it was an important lesson to me to remind everyone after that.
For every dog we see here that is being treated for IMHA (with prednisone), we recommend the use of an “internal band-aid” called Sucralfate. It creates a thick mucous around any possible ulcers and allows them to heal. I recommend it be given on an overnight fast so it has a long time to work. It does interfere with the absorption of nutrition and medications so best to keep it away during those times. While it isn’t a drug, you do need to get it from your vet. It is quite safe and effective.
I am also guessing that he may also have developed pancreatitis, an inflammation of the pancreas which is very painful and can lead to similar symptoms you are describing. The use of prednisone is considered to be one reason this happens in dogs. Your vet can run a specific test for this very easily to determine if this is the case. It is called SNAP cPL Test for Specific Canine Pancreatic Lipase. It is very precise and you will know immediately if this is why he is so uncomfortable.
If the test is positive then you need to fast your dog for a period of time (plenty of water though) when the symptoms seem very bad and then reintroduce him to a very easily digestible diet that has very little fat in it. Fat causes the pancreas to become very active in order to digest it. So the meals should be extremely low fat and with just enough calories to get to the next meal, so preferably small, more frequent meals.
You can also ask for a pack of Carafate to help with nausea and stomach upset so he will feel more like eating. They can also give a shot if necessary.
I would like to see the last two CBC’s and Chemical Screens. I can explain the things on there so you can understand it more. You can use the Urgent Advice page (see it up in the menu items on the right side?) to upload your files to me.
I’m guessing Vally would like to help you with a medication chart so you can get these meds all sorted out according to your schedule.
What questions do you have for me?
My best Patrice
Dear Terri,
I am sad to read this. I had hoped for a better outcome. But I know that sometimes it doesn’t happen the way we want it to be.
You are an amazing Mom, doing all the right things and asking good questions. Everything you did was done with love and great care. I know that Ginger was so happy that you were with her and that is all she wanted. She trusted you to do this and you honored her by taking care of her so carefully.
It is normal to feel grief and also to feel guilt. We have all gone through that “I should’ve, I could’ve, I didn’t, why didn’t I?” But guilt interferes with the loving memories that we have. I know that she would not want you to feel guilty or sad. She would want you to run around really fast, roll around in the grass, get a cold drink and then take a nap under a tree. She forgives you and wants you to not feel sad.
In time the sharp edges will smooth out and only the good things will remain in your thoughts. I promise it does get better.
It also helps to find a way to honor her memory with something special. I honor Chance with this website to help others, never wanting them to go through this alone. Some owners have mentioned that now that they know about this disease they will make sure others know about it too. Doing something special in her memory will remind you of her in a good way.
We are always here if you want to talk. You can come back two years from now if you want or be here everyday.
Love, Patrice
Terri,
I’ve looked into Cellcept (Mycophenalate) before on behalf of previous owners. The main problem with this drug is that it a human drug being used off label for veterinary treatment. That’s not unusual, many human drugs are used for dogs because there is just not enough money or interest to test many human drugs for use in animals. So some veterinary clinics started using it to see if they could fit it into their clinic protocol. So it has been become more popular. That doesn’t mean that it doesn’t concern me that the side effects are not clear in dogs.
So never-the-less it is used in human medicine, and there are some significant side effects in humans on Mycophenalate, enough that I always mention to concerned owners that they should be aware of them and cautious. Here is a human study that indicates some serious gastrointestinal side effects.
https://www.ncbi.nlm.nih.gov/pubmed/21094821
“Mycophenolate mofetil (MMF) was introduced as a new immune-suppression drug in the mid-1990s. It is widely utilized in solid-organ transplantation immune-suppression regimens. Side effects include gastrointestinal (GI) toxicity in the form of nausea, vomiting, and diarrhea. Physicians tend to reduce the dose of MMF or switch their patients to an enterio-coated formula to overcome the side effects. Because GI side effects are well linked to MMF, colonoscopy is not utilized in most of the cases to investigate the diarrhea. However, Crohn’s disease-like changes in the colon, erosive enterocolitis, and graft versus host disease-like colonic changes associated with the use of MMF have been reported.”
So why does this happen? The short story is the way these drugs work is to cause changes in certain cells to reduce their numbers. Cellcept is attempting to lower the number of a certain type of cell that may be responsible for the autoimmune attack. But the cells of the digestive tract can be similar and they can also be affected.
Prednisone is a commonly used drug to reduce gastrointestinal inflammation and you are already giving that.
Looking up the effectiveness of metrondiazole for dogs with IBD, I find this hopeful information from the 2006 World Conference Update On Inflammatory Bowel Disease.
https://www.ncbi.nlm.nih.gov/pubmed/21094821
“Treatment with antimicrobials can be justified in IBD, in part to treat secondary SIBO, and partly due to the importance of bacterial antigens in IBD pathogenesis. Ciprofloxacin and metronidazole are most commonly used in human IBD, but metronidazole is the preferred drug for small animals. The efficacy of metronidazole may not just be related to its antibacterial activity, since there may be immunomodulatory effects on cell-mediated immunity. Further, other antibacterials such as tylosin may also have immunomodulatory effects, and empirically this drug has proved useful in many cases. In fact, a recent study in a rodent model of intestinal inflammation has shown that both metronidazole and tylosin are effective in decreasing inflammation. Finally, cases of HUC have recently been show to antibacterials such as enrofloxacin, suggesting a possible infectious agent underlies this condition. In fact, a recent study has confirmed the presence of invasive E. coli in HUC lesions.”
So, as I have always believed, metrondiazole is very reliable in veterinary treatment for diarrhea and colitis. I will remind you that high doses over long periods of time can lead to certain side effects. I have also experimented with my vet using the lowest effective dose for longer periods of time which were very effective and tolerated. I think I remember that Chance, at 93lbs, should have been getting something like 1000 or 1200 mg a day, split into 2 doses. We dropped that to 100mg twice a day after a short time and it worked very well.
The next thing to look at is making sure that the diet is non abrasive and does not irritate any further. I’ve returned to Mary Stauss’ site DogAware for more help.
http://dogaware.com/health/digestive.html
“In general, you want to stay away from all grains and other starchy foods that take a long time to digest, such as potatoes and corn, limit the amount of fiber (from vegetables), and avoid dairy, to see if that helps.”
Look at your dog food for this:
“Carrageenan, an ingredient used as a thickening agent in many canned foods, has been associated with intestinal ulceration, inflammatory bowel disease (IBD), and acid reflux. While most studies have been done on carrageenan, it’s possible that other thickening agents, such as carboxymethyl cellulose, polysorbate 60 and 80, guar gum, xanthan gum, and agar agar, may also contribute to digestive problems in sensitive dogs.”
“Many dogs with IBD, chronic pancreatitis, or other gastrointestinal problems have difficulty digesting fat and may need a low-fat diet.”
My usual diet for simple diarrhea is scrambled eggs and deli rotisserie chicken. But with the liver involvement you may want to investigate Dr. Dodds Liver Sparing diet. It the top item on this page.
https://www.secondchanceaihadogs.com/nutrition-resources
Mary lists a number of supplements that she recommends. You might try one of these as well. This one, glutamine, would be something I would try if I was faced with colitis.
https://vcahospitals.com/know-your-pet/glutamine
I am upset by the finding by Dr. Dodds about the extreme hypothyroidism. This is something she pushes to be one of the first diagnostic tests that should be run when a dog develops an autoimmune issue. Many vets don’t bother with the testing or they only test one part of it. Then if they see a very low, but normal level, they accept this as perfectly normal and refuse to treat it. Dogs do far better when they fall in the middle of the range between high and low. My breed, Giant Schnauzer, can be severely impacted by low normal thyroid, suffering behavior changes, epilepsy, and as was the case with Chance, profound bone marrow failure.
So please request this brand of thyroid supplement, Thyro Tabs, I have used this for years to treat my dogs. My vet’s medical technician did extensive research to ensure they were providing the best. You can find the product insert on this page, near the bottom. Click on the picture of the Thyro Tabs pill bottle. Print this page and present it to your vet asking for a prescription. Do not accept any other generic substitute, they are not effective in dogs.
https://www.secondchanceaihadogs.com/medication-resources
The liver “damage” is a normal part of using prednisone. The liver processes this drug and liver cells are damaged, releasing enzymes into the blood. These enzymes can become very high, the liver can be extremely sensitive and enlarged. It can feel very uncomfortable for dogs. The important thing to know is that the liver is regenerative. If there was no organic disease prior to this, then it will heal once the prednisone is decreased. Please do not be alarmed but please do use the supplement Denamarin.
I highly recommend the use of Denamarin, a supplement, when the liver is severely damaged. When Chance was so sick from prednisone after several months, Dr. Dodds asked me to send his values from the chem screen test. His ALKP, which has a high normal value of around 212, was over 8600. I started the Denamarin and within a few weeks his value was down to 318. I really stand by my recommendation to use this. You can find the product insert and brochure for Denamarin on this page:
https://www.secondchanceaihadogs.com/second-chance-resources/supplement-resources
Please send me copies of the CBC and Chemical Screen tests. I would like to stay on top of what is going on, these things should have been addressed much sooner. You can use the Urgent Advice page, look at the top menu, and attach the files to this. They come to my email.
I am out of town for a few days and in a place where sometimes I don’t have cell reception. I will do the best I can to keep up.
My best, patrice
Terri,
Dogs with these conditions sure do develop other disease conditions due to medication side effects. The biggest problems are due to the very high prednisone doses. Things like ulcers, pancreatitis, drug induced Cushing’s Disease, skin conditions like staph infections, hair loss, heavy panting, frequent peeing, muscle loss and fat redistribution, inflamed liver, UTI, severe dehydration etc are all attributable to prednisone.
Digestive problems are also a problem especially if the dog is getting antibiotics.
Other drugs like cyclosporine can cause digestive problems.
Some other immuno-suppressant used behave like chemo drugs and can lead to bone marrow suppression which makes the anemia even worse.
We are here to notice those things and help you understand which things are to be expected and those that need quick attention.
I have a link on our site to Dogaware.com. Mary Strauss has been collecting and cataloging canine nutrition and disease information for years. We have a collaborative relationship, she is my go to for diet and disease information.
This page discusses digestive problems, starting with mild and occasional diarrhea. Further down she discusses more serious conditions, like colitis.
http://www.dogaware.com/health/digestive.html
I trust everything she has written, read the information about colitis and other conditions that could have blood in stools. She lists many home treatments, I’ve already mentioned the rice congee. It’s usually a good idea to try one supplement at a time so you can figure out what is helping.
Ah, you’ve picked up on our greatest difficulty in helping owners, the difference between vets treatments. It can be a struggle. We don’t like to make judgments about vets, after all owners need to trust their vets. But sometimes we do try to suggest either playing a stronger role in decisions and care or getting a second opinion.
Occasionally there have been sad stories with vets not having an appropriate emergency treatment protocol. My heart sinks when a vet is only prescribing prednisone with no stomach protection for instance.
I do promise to always politely note when I think the vet should be providing certain treatments or should be more proactive with testing. I am not always satisfied with their response.
You are Gingers best advocate. No one knows her like you do and you spend most of the day with her. Your vet may spend a half hour with her. You drive the bus. They must include you as part of the team that cares for her, not stuck out in the waiting room. Be polite and thank them for their expertise but be firm about your desire to be included in everything and have the ability to make important decisions. If it feels somehow wrong, speak up.
Ask me if you need any help understanding Mary’s information.
Want to know how she is tomorrow.
My best Patrice
So, my concern is that the vet didn’t decide to do a stool sample to see if this is bacterial. So we don’t know exactly what’s the issue. But regardless, dogs are so prone to digestive upset that most vets do just treat immediately, which can be diagnostic, if metronidazole works, then we know it’s inflammation and bacterial.
So diet wise, chicken and eggs are fine. Rice is actually an irritant to the colon. However if you boil sushi rice in a lot of water until it is mush, that is equivalent to it being already digested into sugars. That would provide calories and the rice congee would be gel like. I’m not so sure about the dog food. Most of those special foods rely on ingredients that aren’t necessarily “food.” An alternative to pumpkin is yams cooked until they are mushy. Sweeter tasting.
So, need to identify why there is blood in diarrhea, or treat as if bacterial or inflammatory colitis. Provide easy to digest food, low roughage but soft bulk. Diarrhea alone weakens a dog and we certainly don’t want her becoming dehydrated. That will quickly make her less stable. Lots of fresh clean water.
I wouldn’t let this more than a day or two more without attention.
Patrice
Kerrie,
I am delighted to read about Bristol showing a strong will to live! Dr. Dodds is my guardian angel, having saved Chance, so I am very glad to hear she is helping.
You’re on the downswing right now. The prednisone is probably at the highest dose they can prescribe, you’ve been giving it long enough for some really scary side effects to show up.
As Vally and I both know well, the hardest part of this group of diseases is that the side effects of the drugs seem worse (are worse) than the diseases. But when you start to see small forward steps you can begin to see a time in the future when she will get better and the prednisone can be decreased. The drugs must be used and sometimes that is the hardest thing to accept because we are reluctant to drug our animals to the max.
You’ve added cyclosporine and that will become extremely effective and you will be able to slowly decrease the prednisone. That is why we always recommend a secondary immunusuppressant drug be added, to reduce the need for prednisone. Your vet and Dr. Dodds will explain to you how to do the reduction carefully and slowly. Here is what we recommend for how to decrease prednisone, perhaps a bit more conservative than some vets, but was developed from our experience with dogs we have helped and from some dogs that had relapses when they reduced the prednisone too quickly.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction
In 2007 Chance was extremely sick from just being solely on prednisone. His liver was extremely inflamed and painful. Besides having bone marrow failure (not making red blood cells) he also was not making white blood cells so he needed to be on antibiotics constantly and those made him feel ill too. He had different behavior, as you have noticed, did not want to be petted and behaved antisocially. That is absolutely normal. Do not take it to heart. I let Chance have his space. When he recovered, which took the whole year, he was himself again. He looked good and he felt good. He was not exactly the same dog going in that came out of the illness, but still “Chance.” Vally has had similar experiences with Bingo.
We both committed ourselves to help owners like you because we know how much better it feels to have someone help make uncomfortable decisions. I am also very committed to education because I think it helps us make less emotional decisions. So many owners have no knowledge of these conditions and suddenly find themselves in an emergency room with the vet, who is using all these complicated words, they don’t even know what they are talking about. Then they hand the owner an outrageously expensive estimate. How do you make a good decision in that kind of pressure cooker? You can’t. So we are here to do the heavy lifting; the research, and pass that on to the owner in a way they can understand.
So about transfusions. Physicians and vets use a common term, transfusion trigger, when deciding whether to administer one or not. First they evaluate the findings from the test results. Once they have done that then they evaluate the patient. Are they feeble, unable to stand up and walk to relieve themselves? Does your dog perk up when you or a staff member visit? Even a tail wag is a good sign. Do they seem hungry and willing to eat some food, drink water?
So one dog could have a PCV of 12% but be very alert and perky while a dog with a PCV of 28% can hardly stand. Clearly the first dog probably doesn’t need a transfusion right yet if they are this stable, but the second dog does need it, they are not stable and need the benefits of not only red blood cells but all the other cellular elements in blood that make us feel better. This is the thought process your vet went through, talking with staff and evaluating Bristol.
Make no mistake, Bristol is working very hard right now to get better. She has a strong will to live. I would agree that if you can, honor that. We have seen some amazing comebacks in many dogs. I have faith.
We are always here to help. Any questions you have, let us know.
My best Patrice
Terri,
Metronidazole is an antibiotic that is commonly used to treat dogs digestive issues like colitis.
I have 2 big dogs and my vet will prescribe it for me with not even a visit. It works quickly. I do keep a bottle on hand.
There can be some negative side effects used at high doses for long periods of time. You don’t need to worry about that. Often, a dog will respond to chronic issues with much lower maintenance doses.
The omeprazole is a Proton-pump inhibitor that helps prevent ulcers in the stomach. Prednisone is a caustic medication and combined with strong stomach acid can definitely lead to ulcers. So this drug reduces the acid. Still continue this until you stop the prednisone.
My best Patrice
![bingo-14-5_1200x775](https://www.secondchanceaihadogs.com/wp-content/gallery/aiha-dogs_2/bingo-14-5_1200x775.jpg "Vally\'s Bingo \\"Smile\\"")
![Brigitte_Cleo_Ripley_Enzo_4](https://www.secondchanceaihadogs.com/wp-content/gallery/aiha-dogs_2/Brigitte_Cleo_Ripley_Enzo_4.jpg "Brigitte\'s Cleo, Ripley, Enzo and Guest \\"Rockin\\"")
