Liver Enzymes – Page 5 – Second Chance AIHA Dogs

Keymaster

Hi Beth

You could try a large bath towel used as a sling – spread as widely as possible underneath his tummy/chest a carry him like a shopping bag, but with two hands. We had to do this for a couple of weeks with one of our dogs when he had a stroke & it works well, but I sympathise – the stairs are hell. Please be careful.

I think I’m the only one who has done a fast pred drop with Worzel – everyone else has been able to do the sensible slow reduction as far as I can remember (anyone else please say????). He was really weak before we lowered the pred & we sometimes had to lift him on & off the bed & settee (spoilt or what?). He was very grumpy & uncomfortable in the first 2 weeks of the drop – the withdrawal symptoms make them feel really BAD. He did not want to do anything at all & just lay there moping & didn’t like being touched – he was sore, I know. It sounds like Heathy is suffering the same symptoms – his poor little atrophied adrenal glands just aren’t working properly yet – they need to wake up & this takes time. I can honestly say I felt like absolute rubbish (I can’t say the word I want to say on here!) myself when I came off a longish course of pred. I had to carry a card round with me for ages, so it’s not any easy journey. Poor Heathy must feel an awful lot worse than I did.

I can only tell you that I religiously checked his gums, pulse rate & regularity, looked at his poo carefully for diarrhea or blood (black, tarry is an indication of blood). As he is usually right next to me, he was easy to keep an eye on. There is a risk of dehydration if they have diarrhea or vomiting at this stage & he would need to see the vet. If you are in any doubt about him losing consciousness or being about to collapse, that is when the vet is needed too. Shaking, shock or trembling are also signs of crisis.

Do you think he has really gone downhill fast? If he is finding it difficult to walk & this has happened quickly, I am just a little concerned – has this happened before? There is a big difference between weakness & collapse of course. Excessive thirst is a warning too. If you are in any doubt at all about the pred drop hurting him badly, my advice would be to contact Dr Dodds & maybe go for a 4 or 5 day reduction, rather than 3 days. As you know, we did 50% per week & that was painful.

I think you might be seeing some jaundice – yellowing of gums, eyes, skin – by now if he has a liver infection. Everything in his tests looks like pred effects & I know Patrice’s Chance’s enzymes were even higher than Heathy’s, so don’t get sidetracked with the liver for now – we’ll worry about that when he’s off the pred – first things first. In my experience with patients with severe liver problems, you usually see some degree of jaundice, nausea, a very bad reaction to any fatty food, diarrhea, abdominal swelling. People feel really puky & unwell.

He WILL get through this – I know you will know if something urgent happens & get him to the vets. It didn’t happen to Worzel, even though he suffered – you just know they are not themselves & it’s not nice to see them like that – but it’s so worth it in the end. Getting the drug out of his system & getting the denamarin into it are number one priorities to get him better. He is absolutely gorgeous by the way, as I knew he would be – I adore Staffies – they are wonderful natured dogs – his photos are in the slideshow on the RHS of the screen now.

Any questions, just ask, anytime
Love Sheena x

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Patrice

Keymaster

Beth,
He is feeling very weak because you are doing a rapid decrease in prednisone dosage. We know this decrease is absolutely necessary for his liver health.

When we flood the body with high doses of prednisone we are essentially giving our dog a drug that is similar to the body’s own cortisol, made by the adrenal glands. The adrenal glands sense this high level of cortisol via feedback and they essentially stop making cortisol, they go to “sleep” essentially.

When you begin to rapidly decrease prednisone, you are asking the adrenal glands to “wake up” to begin their work again. They are unable to do this that quickly and it takes time for them to respond properly. At one point you asked how fast this happens. Well, it’s different from one dog to the next and from one human to the next. It’s like weaning off training wheels on a tricycle. Maybe on day one you can go three feet before losing your balance. In a week maybe you can go the whole length of the driveway.

We wish we could tell you what to expect and we have ALL theorized about this, but there are no “set in stone” progressions. In general, on Second Chance, we recommend no more than 25-33% decrease in dosage at one time and with at least 2-3 weeks in between decreases. Always precede any reduction in a med with at minimum a PCV but preferably a full CBC and chem screen. When you get to lower doses that are given once a day (or every other day), give them in the morning to simulate what the normal body rhythm is, to be more active during the day.

These recommendations really stem from the wish to avoid having a dog relapse in their recovery from AIHA IMHA. In some dogs there is a greater risk of relapse if their immunosuppressive drugs are reduced too quickly. I am asking those moderators and others who experienced this with their dogs to speak up here to explain this.

Because Heathy is so badly affected by the high doses of pred, he is going to need to decrease faster. I had to do that with Chance when Dr. Dodds came on board to help him. His liver enzymes were out of sight too.

However, after all I have said, many thousands of doctors and vets know how to reduce prednisone carefully. They use this drug not only for autoimmune diseases but for many other conditions as well. Following their guidance is generally a good idea. Keep an open dialog with the vet during this process to smooth it along. Your vet really should be a phone call away for you right now.

Cortisol is our body stimulator. It helps our body deal with stressful situations like “fight or flight.” It revs up our heart and breathing rate, changes blood flow to the brain and heart, among many many other body systems that prepare us for ACTION.

To you and me stress could be getting caught in a traffic jam when we are already one hour late for a very important appointment. To a dog, stress could be the door bell ringing or you getting up from your computer to get another cup of coffee (are we going for a walk now????)

In any case, dogs tend to go from “off” to “on” with less provocation and with a greater stimulus to activate their body to respond to that stress in their daily lives. They “need” to have a sufficient amount of cortisol to just get by each day. If there is an issue with getting enough, they can respond to stress with difficulty.

What you can watch for at home. Well you are already seeing some of the signs. Extreme fatigue and weakness, lack of interest in household activities. Just not doing right. This is a reaction to low levels of stress like standing up and walking.

What we want you to watch for are reactions to sudden stressful events. If he is highly stimulated and cannot muster enough cortisol to deal with it, there is a possibility he could collapse. This would be a veterinary emergency. Do I think this is going to happen? NO. But we do want you to keep him quiet right now. Try to avoid those things that you know he already finds stressful.

Both Sheena and me have had to take prednisone at one time and then decrease it. We can tell you we felt AWFUL while we were doing it. I really feel for Heathy, especially since he doesn’t know why he feels awful…

For the weakness I can highly recommend a body harness called Help Me Up. I have a LOT of experience with these! I have used them on three of my Giants for knee surgery. They sure make a huge difference. They can be worn nearly around the clock and turn my huge dogs at 90+ pounds into easy to handle suitcases. Even as small as I am I have been able to move Willie around with this harness. I can help him up stairs, walk him, load him in the car and help him lie down or stand up.
http://helpemup.com/

I know, you are short of funds. But here’s what I suggest. Ask your vet to contact the clinic with the specialist you saw and ask if the orthopedic dept has a Help Me Up harness you can borrow until he is feeling better. My vet surgeon let me borrow a harness so it’s not beyond belief that another facility would let you do this as well.

Even if they only have half of the full harness (these things are modular so you can use either the front, the back or both together at any time) that will help you significantly. When you are done with it you can wash it and return it.

Now for the liver biopsy. STOP. Open this paper I am sending you the link to and PRINT IT AND GIVE IT TO YOUR VET IMMEDIATELY.
http://www.idexx.de/pdf/de_de/smallanimal/snap/bileacids/diagnosing-liver-disease.pdf
Diagnosing Liver Disease: A roundtable discussion
“As every practitioner knows, liver disease can be frustrating to diagnose. Today’s roundtable includes internationally recognized experts who share a common goal:
to provide practical information that will help readers diagnose hepatic disease in
dogs and cats.”
What you will find when you read this are how several veterinary experts evaluate, test, diagnose and treat abnormal liver enzyme values. This article points out that there is confusion about this and explain why some vets don’t understand this with the depth that these folks on this panel do.

They will speak eloquently about what a mistake it is to take biopsies for all cases of high liver values. For instance:
“We should use the phrase “cholestatic-induction enzymes” when referring to alkaline phosphatase (ALKP) based on a collection of investigative studies. The activity of ALKP reflects an induction phenomenon associated with enhanced protein transcription. This phenomenon has been widely studied as a response to corticosteroids (endogenous and exogenous).”

What in the world is this saying? Give high doses of cortisone to a dog and you are likely to see high values of alkaline phosphatase. This doesn’t require a biopsy to determine.

What happens if you treat him by decreasing the prednisone, give him Denamarin for two weeks and the ALKP drops to 2100? Isn’t that a sign that the high ALKP was due to the prednisone? I’ve already seen this in Chance.

Here are professionals candidly talking about this in a panel discussion that can guide your vet through this so you don’t have to try to explain yet one more thing to your vet.
my best
patrice

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Beth

Guest

Hi Patrice,

Im a little confused as to who’s advice to take on the pred reduction. Dr Dodds has suggested a reduction to 40mg 3-5 days after the previous reduction from 80 to 60mg. So as i reduced the pred from 80 to 60mg on sunday, this would be a reduction to 40mg on thursday at the latest. Although she hasnt specifically said, i know my vet isnt necessarily supportive of another drop this week, she told me to get the pcv results on wednesday and not do anything before i have spoken to her.
Im so caught between trying to avoid a relaspse, trying to help Heathys liver and trying not to make him feel so awful from rapid pred reductions in terms of his ‘sleepy’ adrenal gland and too little cortisol for normal functioning. I really dont know which way to go. We are due a pcv on wednesday and a full cbc on friday or saturday.
My vet spoke to an internist today and the internist was convinced that it is still the azathioprine that caused the problem with his liver. Apparently, according to the internist “it takes several weeks for the medication (azathioprine) to get fully out of their system… she said she’s had cases of azathioprine hepatopathy that have taken 3-4 weeks to show improvement in liver values”. Although we stopped the azathioprine just over a week ago, and within the following week Heathys liver values increased significantly, even off the azathioprine. My vet is working hard for us, but she has not ever suggested or agreed that the prednisone could be causing some hepatotoxicity/damage. She has shown reluctance for a fast reduction as she is concerned about a aiha relaspse. Rightly so. But I think she is a little thrown, as the ALT value is so high, jumped from 670 to 1736 in a week. She said she expects ALP to be high due to the steroids, but not necessarily ALT, hence her theory about the azathioprine induced liver toxicity.
Im pretty confused myself now.
Oh and thankyou for all the insight into how Heathy is likely to be feeling right now, he seems so tired and weak, and thats the thing – he reacts to very little… Like he cant. A shake of his collar would usually get him excited about a walk, even in the early days of the anemia, but over the last couple of days he seems to react to nothing. Wow, im glad u have educated me on that one. I will be extra careful not to stress him.
My vet is concerned about his increased lethagy wrt his pcv and is eager for a pcv check, but i keep checking his tongue and gums and they are lovely and dark pink.
The ‘help me up’ looks brilliant! I will try borrowing one.
Oh lastly, i wouldnt agree to a liver biopsy without serious convincing or chatting it over with my vet/you all/Dr Dodds and following my own instinct. My vet spoke to me about a liver aspirate and a liver biopsy. Both sound like more stress than im willing to put Heathy through right now, she said the biopsy can bleed etc. i just burst into tears when i heard her suggesting it so i wont be going there any time soon without a lot of convincing, that it is necessary. Besides, he had normal liver values when this all started.
I can see Heathys journey is gonna get tougher/ more intensive as we try to balance the drugs against the disorders.
Wow, this is a challenge. Somedays i almost imagine things are normal again and pretend that nothing has really happened…. But then a drug taking time comes around again on the scedule, or Heathy doesnt jump up like he used to, and i’m reminded that we are in a nightmare still.
Oh, one other thing, any thoughts on the aspirin? (The vet told me we could stop it, is this ok?) I have asked Dr Dodds also and am just waiting out on a response.
Many Thanks,
Beth and Heathy. xx

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Patrice

Keymaster

Beth
Reconnect with Dr Dodds about the decrease and explain what your vet has said and also what the specialist said. She can be very diplomatic and compromise when necessary. Don’t worry about asking her again, I promise she won’t be offended or upset.

My vets took everything she said at her word and that is what we did. To my vets, even in 2007, Dr Dodds was quite famous and they found it quite unusual she would consult like this.

Note the excerpt I pasted? It refers to corticosteroids as a direct cause of the high ALKP. I also want to tell you that Chance was not on azathioprine, only prednisone, and he was, I believe, taking over 80mg a day. Jean wanted that lowered as quickly as possible because his liver was so compromised. His values were higher than Heathy are now.

I know each dog and case are different. However, if this is due to the azathioprine and it remains in the body for a longer period of time what benefit would a biopsy provide to treatment? You must ask at each step How will this improve his treatment. If your vets want to have a professional disagreement about this they should have lunch and talk it out privately.

You must get the prednisone reduced. It is a wonder drug but it is also known for the body wide side effects it can wreak havoc with. So the main question should be by how much and how fast.

I am not quite sure why cyclosporine hasn’t been suggested as that drug has very few side effects. But no matter. Get your vets focused on his care and giving you straight answers.

My country vet is an incredibly smart woman. She said to me at one point during Chances treatment “the liver has more smarts in just a little tiny section the size of the tip of my pinky than I will ever have as a vet in my whole career.” In other words, the liver is working RIGHT NOW to get better. VERY HARD. With or without your help. So just give it some help. Simple diet and the supplements we have talked about.

The easiest place to check pulse is to wrap your hand, thumb on top, around and above the stiffle. Move your 4 fingers up deep into the groin. Press up and there is a good pulse. Other: finger deep into the cavity in back of front largest pad of paw, below the dew claw. Or watch ear tip carefully . Dogs have an inspirational heart rate , thus it pauses briefly when the dog inhales. This feels abnormal and can be frightening . There is nothing wrong.
My best patrice

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admin

Keymaster

Hi Beth

I developed a habit of keeping my hand on Worzel’s chest all the time, especially in bed, because it was may way of monitoring him! I still do it now, funnily enough. Like all greyhounds, he has a very profound, strong heartbeat, so maybe you won’t be able to do the same with Heathy – I’m not sure. If not, Patrice’s groin pulse method is the easiest way by far.

Phil & I were chatting last night about how bad Worzel was with his rapid reduction – he actually remembers him being far worse than I do, so I hope that reassures you. He remembers us having difficulty rousing him when he had been asleep & him being exceptionally tired & not interested in anything at all. I remember he went off his food somewhat as well, but then he had been eating humungous amounts, so don’t worry if Heathy doesn’t want as much now. We made sure he was comfortable & quiet – he didn’t like too much fuss or cuddles because he was weak, hurting & a bit miserable. I promise this all changed after the initial couple of weeks – he was back to himself in no time. When we stopped the pred completely, I noticed a massive improvement & his muscles gradually came back. For him, his sunken bits behind his eyes were hideous (pred head) & made him look like a skull, bless him. It has all filled out beautifully. I forgot to mention (Phil reminded me) that I panicked at the size of his salivary glands, thinking the worst (cancer) of course, but it was just they looked really big because his jaw muscles & everything else had shrunk so much. He was beginning to struggle chewing anything with those atrophied jaw muscles – that’s how bad he was. But we all have to remember that it was the pred that initially saved their lives & we just get through this withdrawal symptom stage as well as we can.

Dr Dodds is a very friendly, down to earth person & will not mind at all if you contact her & explain what’s happened – everything is flexible according to how Heathy is getting on with the reduction. As Patrice says, she is great with other vets too.

Again, don’t get hung up on the liver enzymes, please. Worzel was on azathioprine at full dose (50mg per day) for a long time & it was the PRED reduction & milk thistle that made the difference. I really do think things will improve with pred reduction. Worzel absolutely STUNK (bad wind & smelly breath) on the pred too – that also got less & less at each reduction. We quite often have a laugh about our stinkers on here – the drugs seem to give them awful smelly wind!

So, keep your chin up & look after that beautiful boy – it will a hard couple of weeks, but you CAN do this, no problem. If you are concerned about anything at all, just ask.

Love & cuddles from us all
Sheena, Worzel & Ollie xxxx

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