S.R.M.A dilema - neuro/medical advice needed please

Re: S.R.M.A dilema - neuro/medical advice needed please

Andrew Kent — Fri, 02 Jan 2015 17:47:04 GMT

I think as this case has been under the care of a neurologist that it may be worth discussing the case with them as there may have been a reason behind them suggesting that dose. But it is much lower than what I would routinely use in that situation and would imagine it would be sub-therapeutic. There are a number of labs that offer ciclosporin assays and they will give you a reference range (based on human ranges) but these haven't been shown to relate to clinical effect - i.e. some dogs can have low levels but be well controlled and vice versa so personally I never run them in dogs.

With one of the major differentials of this dogs recent deterioration being an immune-mediated arthritis there is an argument to give it more immunosuppressants if the culture is negative. I'm not the biggest fan of cyclosporine for I-M joint diseases but obviously we can't go back to azathioprine. There may, however, be other options.

Measuring C-reactive protein can be useful when monitoring dogs with immune-mediated diseases as it is a good marker of inflammation. If it stays high then we probably are not controlling the disease very well.

Andy

Re: S.R.M.A dilema - neuro/medical advice needed please

Sara Ramsey — Fri, 02 Jan 2015 17:26:50 GMT

His bloods on 20/11/14 were

alkp 4107

alt 617

BAST 70/157

The ALT was lower than the test 2 weeks previously, when the results were then : alkp 1553, alt 742, fasted BA 123 and it was decided at this point to stop azithioprine.

Interesting about the atopica dose, I was advised this dose from another neurologist. Now I'm worried this dose won't be enough for us to lower the prednisolone but I also don't want to produce a new set of atopica side effects. Also interesting about the cyclosporine assay (again this was advised) - i was hoping the lab would provide information with the results!!

Re: S.R.M.A dilema - neuro/medical advice needed please

Andrew Kent — Fri, 02 Jan 2015 17:12:38 GMT

Hi SER,

Is that the dose of ciclosporin you started with or is this a reduction? Its much lower than the dose that I would normally use for immune-mediated diseases (5mg/kg every 12 hours). It is questionable whether a drug level assay will help you as we don't really know how to interpret them or what they mean.

I think denamarin is a good idea if there has been an azathioprine related hepatotoxicity but wouldn't worry about a liver diet - they are only really useful if you need to restrict copper and otherwise are too protein restricted for most indications.

Was the ALT elevated before or just the ALKP?

Andy

Re: S.R.M.A dilema - neuro/medical advice needed please

Sara Ramsey — Fri, 02 Jan 2015 16:51:23 GMT

Thank you for all your replies, it is much appreciated. My patient is currently on 0.3mg/kg BID prednisolone and has been for the last 4 weeks, he is on 1.6mg/kg atopica bid, he is also on Denamarin and Hills l/d diet. My plan at the moment is to get a cyclosporine assay and try to reduce the prednisolone dose further (< 50% reduction each time).

He has bad cushingnoid signs as noted above and some papillomas due to the atopica but otherwise seems to be tolerating the atopica.

His hock swelling has gone down - currently on amoxyclav, still awaiting the joint culture.

He is also coming in for another liver screen on monday including a BAST. His last test on 12/12/Dec was:

alkp 4672

ast 786

pre-BA 54.8

post feeding BA 97.8

O reports that he is pain free since last seen.

Any further thoughts or advice would be appreciated. Cytarabine had been mentioned but at the moment the condition seems to be controlled and I'm hoping to reduced pred further.

Thanks again!

Re: S.R.M.A dilema - neuro/medical advice needed please

Mark Lowrie — Tue, 30 Dec 2014 11:01:56 GMT

Hi there, this is a difficult one without knowing too much but I suppose I would start by saying this dog should have a really good prognosis – I haven’t lost a dog with SRMA yet… I don’t have much time to reply but here are some quick thoughts…

If pred is a problem – which it clearly seems to be – I would consider adding something else. I have used cytarabine (cytosine arabinoside) as a rescue remedy for these dogs. Depending on the urgency it can be given as 4 separate subcutaneous injections 12hrs apart at a dose of 50mg/m²or as a continuous rate infusion over 24 hours at a dose of 100mg/m². The former would take 2-3 weeks to take effect whereas the latter will reach steady state within 24 hours. This would then give freedom to reduce the pred a little more quickly (there is no ‘correct’ regime here) than you otherwise would (though I was uncertain of the current dose?). I would then repeat the cytarabine via subcutaneous injection (i.e. 4 x 50mg/m² injections every 12 hours) every 3 weeks until the dog is in clinical remission and increase the gap of the injections by one week each cycle to reach a gap of every 6 weeks between injections. At this time I would hope the dog would be doing well and the drugs can be discontinued completely.

Sorry for the haste of the reply but hope this helps.

Oh, and the swollen hock and cytology do support a concurrent polyarthritis but this doesn’t change treatment or prognosis.

Re: S.R.M.A dilema - neuro/medical advice needed please

Anthony Dennison — Tue, 30 Dec 2014 09:55:13 GMT

With a swollen right hock that had no bacteria on cytology, it could be a sterile inflammation which could indicate another immune mediated condition, despite being on steroids. Or there could be a primary cause that has been hidden and this has caused the second problem.

Although he looks bad now, he is only 12 months old and most of the effects of steroids are reversible, yes in the short term his body is taking a beating, but in the long term you could still have a dog healthy enough to be a family pet, just not win any shows etc. Try looking at it from short term cons v long-term pros kind of angle?

Could you change on to medrone from prednisolone to try and make him less PU/PD? I don't know if it is as effective for SRMA.

Re: S.R.M.A dilema - neuro/medical advice needed please

Sara Ramsey — Tue, 30 Dec 2014 09:24:16 GMT

Thanks Martin for your reply,

He is stable at the moment wrt to pain: eating and ambulatory. so I'm not really needing to refer him for more emergency reatment - it's more what his long term prognosis is regarding the effects of his medications.

Re: S.R.M.A dilema - neuro/medical advice needed please

Martin Atkinson — Tue, 30 Dec 2014 09:07:15 GMT

I'm afraid I am of no help with this other than to add a touch of realism. You may rightly declare that this is beyond your realm of confidence and if there is no-one else in the practice who is able to come up with a plan then a frank discussion with the client is in order. Euthanasia is a very valid treatment option in this case as its prognosis is poor and should not be considered a failure. You say the local referral practice is only open for emergency but I wonder how far a seriously ill dog has to be before it becomes an emergency especially if they have already seen it. IMO this is one and they need to live up to their responsibilities. If they still won't play ball there are so many referral practices around including veterinary schools that unless you are completely in the middle of no-where there has to be something within an hours drive or so. I guess it depends how dedicated or indeed realistic the owners are.