LONG -- but all good news. Very IMHA specific. Please read particularly if you have a dog taking Atopica.
We went to UF last weekend, and I just honestly haven't had a chance to "update" everyone (and the IMHA - immune-mediated hemolytic anemia - stuff that is archived on here) on how Billy's doing.
Let me say first, this is all really pretty darned good news. Some concerns, and my biggest reason for posting this is particularly because we've learned a LOT more about Atopica (dog cyclosporine).
For those who haven't followed Billy's stuff a 'capsule' of the story thus far --
5/06 Billy had a senior blood panel (I just had a gut feeling he wasn't feeling very well) that showed he was MEGA anemic. We went thru this long, scary process of trying to figure out if it was tick disease, IMHA (or IMHA triggered BY tick reaction) or what. Then mid-June, when we tried to treat him FOR tick disease that really torqued-off the body and he 'crashed' BADLY -- his hematacrit zoomed down to 8 (normal is around 40-50)-- which is typically lethal. He didn't respond at all well to any of the drugs - he had SIX transfusions between 1st week of June and July 4, 2006/
He started on mega doses of prednisone AND Atopica (dog cyclosporine). Atopica is a drug that has been often used for "allergies" and in mega doses for various immune-suppression things that are immune-mediated.
It took 6 weeks (during June/July 2006) to stabilize him (he spent 3 weeks up at U FL in their ICU). Weaned him off the pred first (that took until the end of October) and then slowly slowly started to wean off the cyclosporine. He bobbled a bit so we weren't able to actually begin to wean him off the cyclosporine/Atopica until the end of January.
Typically they want you to wean off slowly so the body doesn't get the idea to go after itself again. (that's what immune-mediated disease is -- the body's own immune system targets the body and begins killing itself and the immune-suppressors are specifically TO pummel the immune system into submission).
MEGA side effects to these drugs. There can be vomiting/diarrhea but Billy's Achilles' Heel has been urinary tract infections. HUGE nasty ones that have run almost concurrently one after another.
Since March we've been seeing some significant 'side effects'. All along I've been trying very hard to minimize any 'damage' the drugs may cause to his body. Huge huge doses of milk thistle, Chinese herbs, even Prilosec given twice a day (not the usual once, but TWO times a day). We've done blood tests every month -- every single time we'd change the dose of Atopica we'd get blood pulled.
Because he's also on thyroid medicine (Armour thyroid) we've also been monitoring that closely because the steroids and pseudo steroids/immune suppressors mess with the thyroid in a big way.
The liver tends to be the most at-risk organ (hence the huge doses of milk thistle to 'detox' the liver), but I've been concerned all along about the fact that the back-to-back UTIs were being so hard on the bladder/kidney are. I lost a dog to renal failure 3 years ago and frankly it's not something I ever want to repeat.
We were seeing the bad kidney numbers creep up in the blood work. In an effort to see if his body was going hyper thyroid on me I had his blood pressure checked again and oops -- it's borderline 'high'. NOT good. He's also dumping protein in his urine (that's a big bad no-no if you know anything about renal problems) AND his blood isn't storing *enough* protein.
So I wanted UF to see him for sort of a "one year" check up (because it was about this time last year when they really decided he was "stable" enough to begin wean off of the prednisone). Surviving IMHA for one whole year is a big huge deal.
So since last weekend was the Dog Owners and Breeders Symposium, I went up a day early so Billy could have a ton of tests on Friday.
Goals:
1. Ultrasound -- a) to see how the liver fares; b) to see what the bladder/kidneys look like and to see if we see ANY masses or abnormalities (immune suppressors often are followed by cancer- it's a big concern).
2. Super chem. and full CBC blood panels -- again to put the whole picture together of how the body is doing and check kidney levels too.
3. Big urinalysis -- particularly they wanted to take the protein/creatinine ratio to see if there was cause for concern kidney-wise.
4. Aspirates of two areas -- a lipoma on his chest (having a mega immune compromised dog you don't do surgery until there is NO alternative) which has subtly changed in texture over the last few months. Also an aspirate of this hip that has been "swollen" for a lack of a better word. No pain evident …. so what's under there?
5. From the past few blood tests he looked dangerously close to having Cushing's although he was completely without symptoms ("asymptomatic").
My concerns:
1. Now his blood is TOO thick. His 'crit is about 50 which is too high for a cocker. And his blood is sludgy -- they drew blood on him about a month ago and within literally 2 minutes it became a stringy MESS -- scary looking blood sample.
2. The blood pressure -- he's been acting a bit … weird. Kind of "My way or the highway" -- NOT typical for him. Sometimes anxious and unable to settle.
3. The protein IN the urine and the low protein in the blood have me freaked -- that's a sign (about the earliest you get) of renal failure. Noooooooooooooooooooo I don't want to go there.
4. Wanted to talk about wean-off schedule -- can we kick it up a notch and get him OFF this stuff before I have mega problems please??
Tests (not a cheap day at the vets)
A. Cushing's (adrenal problem)
B. Bile acids test (looking for liver problems)
C. Ultrasound of all organs and that left hip that's been swollen (but not painful)
D. Aspirate of lipoma on the breastbone and of hip
E. Blood pressure
F. urinalysis and a protein/creatinine ratio also taken from the urine
G. super chem. blood panel and CBC to check for liver/renal problems etc.
H. thyroid (just T4) to see how high it might be (do we need a full panel done).
I also wanted the Acupuncture Dept at U FL to see him (they've worked on him all along and were part of why he ultimately began to respond so well and re-build the blood)
Results:
[a] NOT Cushing's - that was negative
Bile Acids test was PERFECT -- the milk thistle HAS kept the liver happy.
[c] Ultrasound -- no masses found (RAH), the bladder looks "cystic" (sort of toughened) which is typical because of the frequent UTIs but aside from a tiny bit of liver enlargement HE LOOKS GREAT.
[d] Lipoma on breastbone IS just a lipoma -- it's gone a bit fibrous but not dangerous. The hip aspirate ALSO shows just a fatty lipoma.
[e] Blood pressure was high -- like 220. But he was more than a bit ticked off because they fasted him SOOOOO long. This is a boy who NEEDS to eat twice a day and he hadn't eaten since the night before at 7 and then they never fed him until the next afternoon at FOUR p.m.!!! They told me they thot the BP literally wasn't valid because he was so agitated.
[f] protein creat -- they couldn't take it because there was blood in the urine. Either they nicked him when they aspirated the urine (had to be a sterile urine draw) or there is a mild infection that's not showing (either likely).
[g] Blood work came out great -- except he IS spilling protein into his urine and protein is too *low* in the blood. (both of those point to renal insufficiency).
[h] thyroid looks FINE -- and my vet has also been working with Dr. Jean Dodds so we've checked this in several ways so I'm satisfied it's ok.
All along the vets at UF have maintained Atopica was supposed to *not* hurt the kidneys but I haven't bought it -- to me anything that causes back to back to back to back HORRIFIC UTIs can't be good for anything touching the urine - kidneys, bladder, etc.
I took him the Monday after to have a 'caught' urine sample re-done to see if there was still blood - there was NOT so they did the protein/creatinine ratio and it's high. Not fatally high -- (it should be less than "one" and it's 1.9 -- but that is a 'ratio' -- and since the protein is way LOWER than it should be but the creat is FINE it's a bigger disparity than it would otherwise be). But again -- that's pointing to kidney problems.
The blood pressure WAS still high. Monday on the old-style Doppler cuff it was 150 and on the electronic BP it was 176 (and 180 is the 'bad' threshold). A year ago I had it checked and it was 135 & 150 then (same two machines at the same vet clinic). In dogs they only report the 'upper' number usually, unlike in human BP. But that upper number should honestly be very similar to what ours is. 176 is way way too high for my liking.
So the upshot is, he has some "renal insufficiency" -- the kidneys aren't doing the whole job -- and probably never will again. So now we try to minimize the damage even more. (MORE MILK THISTLE) If I can just keep him out of renal FAILURE. Please Lord. That is my prayer --
I think the danger of the damage to the kidneys by the Atopica is greater than the danger of a recurrence of IMHA at this point. So, with all the vets blessings we're going to ramp up the wean-off. Rather than the month or 3 weeks between we've done all along I've gone to 2 weeks and drop.
Big huge step today, Sunday …. I dropped the Atopica down to 10 mg. 2 weeks at that level and then I'll have to 'pulse' it (a day on/day off) for 2 weeks and then stop it completely.
With Atopica you are restricted by the size of the caps. You can't break them. They come in 100's, 50's, 25's and 10's. No smaller. Where with Pred you can either break them or get a smaller 'dose' at any pharmacy you can't with this. A compounding pharmacy can't even help because the Atopica is a DOG drug formulated way differently for absorption than the human cyclosporine drug.
THINGS I HAVE LEARNED:
The vet community is changing it's mind about Atopica. Up at UF for the last several years, in the allergy portion of the Symposium Atopica was highly touted as great with few side effects. NO MORE. IN fact, at UF they aren't using it FOR allergies hardly at all -- *just* for immune-suppression purposes. That's a major switch in policy in the past year.
My holistic vet checked out the vet-only websites (mostly dermatology sites) and the two biggie side effects at this point indicated in "long term use" is **High blood pressure** and **renal insufficiency**. Renal failure happens far far too often. Especially in those cases where people didn't know what to look for.
Catching renal problems **early** enough in dogs so you can still DO something about it is a big huge problem.
The blood pressure scares the tar out of me -- that's why I'm seeing the "grumpy dog" stuff. It's not thyroid -- we've ruled that out
So the holistic vet and I are working hard to keep the body detoxed and stimulate the kidneys AND to get the immune system back on line *properly*.
****MILK THISTLE****
I can't even emphasize how important this has been. Even the 'regular' vets are admitting the milk thistle has prevented damage.
The AKC has actually ASKED FOR and is sponsoring a clinical trial to be run in the coming year on the use of "silymarin" - a/k/a milk thistle and it's various uses and effectiveness in curtailing damaging. This isn't a study by and for holistic vets. This is a clinical trial test the AKC has asked to have done ON AN HERBAL. That's quite a big deal.
We've got a good chance that the 'renal insufficiency' isn't *damage* as much as it is just the drug screwing things up.
So, I haven't diminished the milk thistle -- in fact he's taking bigger doses of it than ever. (tincture of milk thistle -- he takes FIVE droppers full twice a day -- that's 2 /2 times the human dose) -- but from everything my vet and I are able to find out -- it's the high high doses that are most effective for the kidneys.
THEREFORE
If you have a dog who is on Atopica even for allergies -- please please be cautious. The fact that Billy's been on such huge doses of Atopica for 14 months now with so little damage is flatly amazing.
The Adventuring English cocker spanYELL is still doing well. Prayers are STILL coveted -- particularly since we've ramped up the "wean off" to get him off the drug quicker. But the risks have increased and so far, he's done SOOOOOO well.
Sorry, again, this was so long, but I feel like I need to memorialize this. I so often get emails from people telling me it's encouraged THEM to see how well Billy's done with the IMHA.
