Diagnosed 6/21/19 – Hanging Tough!!! – Page 2

Allan

Guest

Hi Patrice,

A quick update. Since her last check, Zoe started becoming noticeably weaker…..particularly in her hind end, and to the point of pretty much being unable to even get up on her own the past couple of days. As I said in my previous post, once she’s up, she’s okay in general and moves around okay with the exception of going up steps. Still, despite being weaker in general throughout all of this, it had never been to the point of her not really being able to get up. So, off to the vet we went asap yesterday afternoon. First obvious order of business was to check her PCV. Based on her general appearance and alertness, I had a hunch that it was going to be fine, but didn’t say anything out loud for fear of jinxing it. Lo and behold, she has now come up to just under 35 since Friday! Great news for sure, and took a huge load off our shoulders so we could completely focus on her increasing weakness, which we have.

I’d previously mentioned that after consultation with my vet team, we’d decided to go with Heartgard for heartworm prevention, Seresto for fleas/ticks, and stick with the Proin for her incontinence. I gave her the Heartgard Monday and so far, no issues with that. However, I dug deeper into the side effects of Proin and found that it can indeed cause muscle weakness, tiredness, and several of the other symptoms she’s been showing. I know that prolonged dosing of prednisone at high levels can cause similar symptoms, but why risk possibly having TWO things going against her at this point??? Long story short, after telling the vet my theory/opinion about the Proin being a possible contributor to the increased weakness she’s experiencing, we agreed to leave nothing to chance and have stopped it. At this critical point, any incontinence she has is a small price to pay where her mobility and overall well-being is concerned. Her numbers have been relatively good and stable now for several weeks, so I’m hoping if they still look good when I take her back on Friday that we can begin discussions about tapering the prednisone. A delicate, cautious and patient process that I’m well aware of, but getting her weaned off of it and the other meds can’t happen soon enough. So ironic that something so critical to saving her life is also proving to be so detrimental to her body. It continues to be a really hard thing to witness, so I’m hoping my vet team evaluates the numbers and sees fit to begin tapering down soon. In the meantime, I’m hoping that we’ll see some improvement from removing the Proin. Oh, and fyi, we also removed her Seresto collar for now just to rule everything out.

So that’s where we are as now. The vet agreed that walks (not too long) once or twice a day are a good thing, and we certainly agree based on Zoe’s overall appearance and activity level after them…..particularly after the evening one when she seems most alert, mobile and engaged. Any other thoughts or opinions about what we could be doing to diminish the prednisone-related muscle weakness/atrophy/wasting would be great and most welcome.

Thanks in advance!
Allan and Zoe

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Patrice

Keymaster

Allan,
Sorry for the delay in responding. I’ve had some serious technical details with the website but I finally was able to fix some of the problems.

So good to hear that Zoe is still doing ok! Your vet is correct, you are treating her as best as possible right now. A PCV HCT of 30 is considered moderate to mild anemia. It’s not serious. Her body is working very hard to recover and has some difficult things to overcome.

Indeed the prednisone is a very strong drug. This is why Dr. Dodds and now many other vets are using a secondary immunosuppressant, like cyclosporine, in order to shift the job away from the prednisone and onto the cyclo. This gives some wiggle room to begin slowly decreasing the prednisone.

Cyclosporine is an interesting drug. Years ago when human medicine began exploring heart transplants the biggest worry was rejection of the heart by the immune system. These early patients were put on high dose prednisone to prevent that. It wasn’t too long before they realized that this was not ideal for the patients, the side effects were global and made the patients very sick.

So cyclosporine was eventually discovered and developed as the perfect immunosuppressive for these patients. It is a fungi and has the amazing ability to target just the T-Cell lymphocytes in the body, also known as killer t-cells. These white blood cells receive their instructions from the thymus gland and sometimes in autoimmune disease they can go rogue, turning on “self.” The side effects of the drug are minimal compared to prednisone. Dr. Dodds started using the human form of the drug to treat dogs many years ago. Later, Atopica, the veterinary brand of cyclosporine was researched and tested for canine atopic dermatitis, dog inhaled allergies. Amazingly dogs responded to the drug well and it began to slowly be utilized in some clinics for autoimmune diseases like AIHA IMHA, bone marrow failure. Chance was treated with cyclosporin for his bone marrow failure and it saved his life.

So you are seeing the most common side effects, rear end weakness, body fat and fluids shift and are redistributed to different locations in the body giving it a pot belly look, the muscles atrophy especially around the head, constant drinking and peeing, hair loss. This condition is called Iatrogenic Cushings Disease. It simply means that a drug is causing the condition. Organic Cushings Disease is a disruption of the adrenal glands, usually caused by a tumor, that releases too much cortisol in the body. Iatrogenic is the use of extreme high doses of prednisone that are equivalent to the body’s cortisol but too much. It has global effects on every part of the body. Once you remove the prednisone most of this will go away.

We have a couple of resources that go into depth about the side effects. See this page, and just click on the pictures of the articles to view the content.
https://www.secondchanceaihadogs.com/dermatology-resources

I’ve also written up a prednisone reduction guideline. This was developed from years of working with owners on this list and noticing that this disease seems prone to relapse when the drugs are reduced too quickly. Every vet and clinic has their own reduction protocol, but sometimes theirs is too rapid, as far as we are concerned.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

So one of the organs that is most effected by prednisone is the liver and I imagine if I looked at your chemical screen I would see very high values for ALKP and ALT. These are enzymes released by the liver as it processes prednisone. This involves cell death of the liver. But, unless there was organic liver disease prior to this condition, the liver will regenerate and recover back to normal. So this inflamed liver is very painful and is probably another reason why Zoe is feeling under the weather. I always recommend Denamarin (a combination of SAMe and Silybin ) to support and heal the liver. When Chance was at his worse his ALKP was much higher than normal. Normal high is around 214, his was upwards of 8,000. He was in great pain but the Denamarin, given nightly, quickly dropped this number down towards 300. I was very pleased.

Needless to say, her body is very deconditioned and it is wise not to stress her too much with activity. The joints are loose and the muscles are not supporting her body weight well. This can progress to orthopedic injuries. No type of active exercise is going to build up her muscles right now because of the prednisone. Doing simple joint mobilizations and massage is probably the best exercises you can give her now.

Do not worry at all about the drug for heartworm. It is dosed in minuscule amounts. If a dog were to contract heartworm, the vet would use the same exact drug to treat with but it would be in very high doses every day for months to kill off the worms in the body. So you are giving her a very small dose, just enough to kill the larvae at a very early stage. Dr. Dodds advised me to use Interceptor for Chance and dose it at 45 day intervals, that is still preventative but there is zero wiggle room if you forget. So I still dose at 45 days for all my dogs. This information was from a study done to see how long the effective dose would be. So even if you dose every 40 days you will be fine. Manufacturers are probably right when they think people forget to give the drug properly every month!

Ticks are just as worrisome, if not more, because they can carry multiple tick diseases. All of these are extremely serious for humans and dogs. Be vigilant about checking her daily for ticks. But even then some early ticks, nymphs, (also called seed ticks and are so small they can’t be detected.) However they do carry disease. One suggestion is to bath a dog with Ivory or Dawn in the shower immediately after returning home to rinse away all the seed ticks. Towel towel towel and comb comb comb.

I told you I had to stop the Proin for my older Giant. She began having syncopes and really stopped eating. My vet suggested we try Incurin and it has worked very well! She is doing much better, eating, is more active and back to being able to jump up on the couch. The nice thing is that though you start at an initial loading dose, you can easily decrease it until you are only giving it sometimes as little as once a week. I do recommend this.

I agree, Blue Pearl is an excellent facility and the owners we have helped who used this clinic all said wonderful things about the staff and the care.

So a PCV of 30 is a good number. I have noticed over the years, informally, that many of our recovered dogs never get back up the normal average PCV HCT of 45. Some tend to hover around 36-38. But as I explained, the reticulocyte value is far more critical to monitor. Once you see 1% and 60,000 absolute reticulocytes on your CBC’s that is indicating that her body is satified with the amount of oxygen reaching her body cells. Whatever the HCT is at that point is going to be her normal value.

I know you want to know -why- she isn’t up above 30. Keep your eyes on the reticulocyte value each time. If she is regenerative you should see values like 1.5-2% or higher and maybe around 80-100,000 absolute reticulocytes. If her body is ok, you will see 1% and 60,000. Anything below this is consider non-regenerative and means the body is not meeting the need to send more O2 to the body cells.

Another thing to consider is that we may never know the exact combination of triggers that led to this. There may be one still in play that is causing this resistance to get over 30. One complex reason is a condition called Anemia of Chronic Disease. This is difficult to explain. In simple terms there may be some condition in the body that is not getting better. Often it is related to inflammatory cytokines, that causes an overall inflammatory response in the body.

Here is an Merck Manual discussion of anemia of chronic disease. It’s not easy to read or understand but it is often the reason why dogs continue to remain mildly anemic. If you have questions after reading this please ask me to help explain it.

https://www.merckmanuals.com/professional/hematology-and-oncology/anemias-caused-by-deficient-erythropoiesis/anemia-of-chronic-disease

Keep us up to date, anxious to hear when you start decreasing the prednisone.
my best, patrice

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Allan Brown

Guest

Vally and Patrice,

I don’t really know how to begin this post, so I’ll just go ahead and get right into it.

Zoe’s condition continued to deteriorate after my last post. By Thursday morning, it was all she could do to remain standing to use the bathroom even after I’d carried her outside. We went back to the vet first thing Thursday, where a blood chemistry test revealed liver function numbers that were off the charts, indicating that she was in liver failure. She also had developed a severe UTI, which we never realized because of her frequent urination, one of the many awful side effects of the prednisone. We left her at the vet where she received IV antibiotics and fluids for the rest of the day. Our vet gave us the option of either leaving her there overnight, at our local 24-hour emergency clinic overnight, or bringing her home. She wasn’t going to receive any more medication overnight, so given her dire condition, we obviously chose to bring her home. We agreed on the advice of our vet to give the antibiotics until the next morning to kick in, at which time she’d hopefully show some improvement. Our hearts sank as she continued to deteriorate overnight, and as of Friday morning, showed no noticeable improvement or response to the antibiotics. Friday morning, she could not stand at all and rather than put her through the additional stress of yet another vet visit to check numbers we knew would not be improved, we finally accepted the reality of where we’d arrived in this fight.

My vet, her tech and one of my priests from church arrived at our house late Friday morning. My girlfriend who lives with me was also here. After receiving much love from all of us and a beautiful prayer and blessing from my priest, Zoe Brown crossed the Rainbow Bridge at approximately 11:45am EST on Friday, August 16th. She passed peacefully on her couch and in my arms, surrounded by immeasurable heartache and love. If this had to happen, I could not have asked for a more perfect transition to her next life. If it wasn’t in the cards for her to win this fight, our top priority through it all was to do everything in our power to make sure she passed in the comfort and peace of her home. Despite my immeasurable pain, I do take great solace in this fact and that she is no longer suffering.

I am shocked, in utter disbelief, inconsolable at times, and just basically numb. We got her the absolute best veterinary care possible and left no stone unturned, but in the end, it wasn’t enough. It just wasn’t meant to be. I can’t believe that just as we were ready to begin weaning her off the prednisone, something else slipped in behind everyone’s back and took her down so ruthlessly. To say that it’s cruel and adds insult to injury is an understatement. We learned firsthand just how awful this disease is along the way, but its final blow has literally taken our breath away. I’ve lost numerous dogs throughout my life and have grieved tremendously for them all, but this time is different. To see my beautiful girl taken from the pinnacle of health to what she became in 2 months has left me scarred like never before. My healing process will no doubt be long and difficult, and I pray that one day I’ll be able to look back on her life cut short with only happy memories. And trust me…..there was no shortage of those. That was my girl. She loved everyone and was just happy to be alive.

I want to thank you both for taking so much of your time to post all of the incredibly useful information. I have already begun spreading the word to those (like me 2 months ago) who have never heard of it and telling them what I know. I pray that Zoe’s passing will not be in vain and will help others to make more educated decisions regarding the care of their dogs so as to avoid coming face to face with this absolutely horrible disease.

Hug your babies. Don’t take one minute with them for granted.

Love to you all,
Allan (and Zoe)

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Patrice

Keymaster

Dear Allan,
I am so very grieved to read this. I had not expected to hear this.

I know that as owners we try so hard to make sure we do everything to fix what is wrong. We know our dog is relying on us to make it all good again. But sometimes the thing we want most is elusive, just out of reach. The more we want it the further it slips away.

Those of us who struggle with these dire conditions feel enormous guilt at some point. We are so hard on ourselves. I want you to know that you did everything right. You used the best clinic, learned everything you could, stayed positive and trustful. But the most important thing you did was to be with Zoe and that was truly what she wanted most.

Dogs do not fear death, they have no way to imagine the future. I am positive that Zoe lived in the moment of each day and was perfectly satisfied for it to be that way. I am also sure that she would not want you to feel so responsible and hurt so much. She would want you to run around really fast in a field of grass, roll around in it, get a nice cold drink in a stream and then take a long nap under a shady tree.

I know this is so fresh and raw. Time will smooth away the rough edges and only the wonderful memories will prevail. You both loved each other so much that it is worthy to fill your thoughts with the things that you both enjoyed.

I do know that your life will change and you will be different in many ways you do not understand quite yet. People will meet you and they will notice something appealingly different about you that they can’t quite put their finger on. But it is Zoe within you that they sense. Your life will be full of quiet grace and empathy for others.

As Zoe knew, without words, humans need to be reminded many times a day how much we should celebrate our day, how often we need to remind those in our life how happy we are that they came home, that the best things are eating with our family, going outside to play and relaxing on the couch together in the evening.

We are always here on the “couch.” You can come back a year from now, sit down and we will still be here to listen and help you remember beautiful Zoe. Perhaps in the future you will want to spend some time on this forum helping other owners, listening to them and giving them advice. When you are ready to do that please let us know.

My deepest sympathy to you and your family,
Patrice

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