PLE

RE: PLE

Andrew Kent — Tue, 04 Sep 2018 20:16:40 GMT

Great news! Thanks for the update - they can be very rewarding cases when they go well!

Andy

RE: PLE

Sarah Keir — Tue, 04 Sep 2018 19:13:08 GMT

Thank you for updating us! I have a similar case at the moment and additionally the clients are working their way through every vet in the practice rather than coming back to me! I guess I must of been too hard when I stressed to them how ill their dog was! (ascitic, albumin 12, massive weight loss - but still lively and eating)

RE: PLE

Anthony Dennison — Mon, 03 Sep 2018 09:50:15 GMT

Dragged this one back up as it's good news.

Just over a year since I told this dog's owners that he was on death's door, and that they needed to take him home to say goodbye... I saw him for a check and he looks fabulous! Hasn't been on any medication for over 2 months, in excellent condition, no ascites whatsoever, all muscle mass returned, coat looks great! He's been officially 'signed off'.

The owner has been properly dedicated, doing home cooked diets to start with, regularly liasing with me. Don't think this dog would have done if he was anyone else's pet.

RE: PLE

Andrew Kent — Mon, 18 Sep 2017 21:31:30 GMT

PS congrats on the wedding - enjoy married life :-)

RE: PLE

Andrew Kent — Mon, 18 Sep 2017 21:30:01 GMT

Thanks for the update Anthony - I agree its a little difficult to know what the future will bring but sometimes it just takes something to tip the balance in your favour and away they go!

Andy

RE: PLE

Anthony Dennison — Mon, 18 Sep 2017 09:50:53 GMT

Update on this case:

I saw the dog just before I was off for 2 weeks to get married, and he looked horrific. Really flat, lethargic, dehydrated and no muscle mass what so ever. I told the owners that because he wasn't eating, and because the diarrhoea had been so bad, he was just malnourished and starving to death. We did discuss PTS, but the owners wanted him home to say proper goodbyes to him. Gave an injectable steroid and some B12 and told them to come back at the beginning of the following week.

Came back from 2 weeks off and this dog was my first appointment. The bloody thing ran in barking, looking loads brighter. Still like a skeleton, but the ascites had reduced too. Whilst I was away, before admitting defeat and booking in for a PTS, the owner has started liquidising his food and syringe feeding him. After a couple of days of this he started eating on his own and has gone from there.

I realise this is probably just a temporary thing, like a natural variation in severity of the disease and the dog will go downhill again soon, but the difference in the dog is unbelievable!

RE: PLE

patrick murphy — Tue, 15 Aug 2017 11:20:38 GMT

in my limited experience of these (get at least 1 good one per year, and manage with past guidance from Andrew), I am amazed that after all of the heroics etc. of diagnosis and getting/keeping them alive, the owners are obsessed with returning to their choice of supermarket food, and will not invest that little bit more to keep them well!!

RE: PLE

Martin Atkinson — Tue, 15 Aug 2017 10:44:11 GMT

I would be getting pretty impatient with this owner now and having a frank discussion with words to the effect of you may be better off going somewhere else I can't manage your dog's condition if I can't trust you to follow my guidance so I would recommend a referral.

On a slightly more practical note: for the ascites try Torasemide instead of frusemide, I've had good success with dogs with CHF where even max doses of frusemide are not working. Spironolactone is a pretty ineffective diuretic at the best of times.

RE: PLE

Anthony Dennison — Mon, 14 Aug 2017 19:20:22 GMT

Thanks Andy, helpful as always!

RE: PLE

Andrew Kent — Mon, 14 Aug 2017 18:04:11 GMT

Hi Anthony,

Sorry to hear things are not going well, PLE cases are challenging and there is a reason that around 25% of them end in euthanasia. Difficult to know if its because of sinister underlying disease (lymphoma) or severe inflammation or other.

Have you rechecked the bloods? be good to see what the proteins are doing.

In terms of immunosuppressants, if chlorambucil hasn't improved things over 3-4 weeks I would consider switching to ciclosporin. I would also be cautious with your pred dose - I never give more than 2mg/kg/day to dogs as there is no evidence it is any more effective but will have more side effects. so i would drop this dose down further as it may be contributing to weight loss.

Another strategy i occasionally use is switching to injections of dexamethasone for a few days in case the gut is so diseased that the drug is not being absorbed.

But the worse the initial response to drugs often the worse the prognosis.

Andy

RE: PLE

Anthony Dennison — Mon, 14 Aug 2017 17:22:19 GMT

Just an update on this case:

The dog initially ate the RC Anallergenic well, but the owner has always wanted to add something as he thinks the dog is very fussy. Because of this I had heard using novel proteins like ostrich or kangaroo meat can be used, so he has been using that. On chlorambucil 2mg EOD, was on 4mg/kg pred but lots of side effects so dropped to 2mg/kg/day.

Dog has never really improved. Still has an abdomen full of fluid, sometimes it is completely taught, othertimes not as bad. He's constantly lying on cool surfaces to get relief. Marked muscle wastage over his whole body. Managed to get his stools normal for about a week, but the owner keeps reading things on the internet and trying different things, like small amounts of carrots, cabbage water, probiotics with added fibre etc... He is only trying to help his dog but so far I haven't seemed to get across the importance of stability and routine to him!

The owner wanted to stop the chlorambucil because he's read the side effects can include GI issues, and he felt that on the days the dog was getting the dose there was more borborygmi and abdominal discomfort - as this was the short period he seemed to be doing well I suggested we trial it. He missed 3 doses (about a week) and has deteriorated again so we're back on that. To try and diurese some of the fluid off his abdomen I dispensed spironolactone and low dose frusemide, which hasn't made a difference.

Owner is asking me whether it is worth using budenoside (because of more research he's done). I've said probably not because if prednisolone isn't working this isn't likely. Also shut down the idea of lomotil.

I realise that this is probably one of those cases that just isn't going to respond to whatever I use, and the owner isn't helping himself by constantly changing the diet, but the poor dog is looking pretty pants now and I just feel for him. Is there anything else I could try? Ordering in some vitB12 to give, as it can't do any harm and may help.

RE: PLE

Anthony Dennison — Tue, 13 Jun 2017 14:27:29 GMT

Fantastic! Thanks for the quick response. Just got to convince the owner to pay for it now! I've managed to get an open bag of RC Anallergenic for him to take FOC so that's at least a bit saved.

RE: PLE

Andrew Kent — Tue, 13 Jun 2017 13:14:36 GMT

Hi Anthony,

I use quite a high dose in PLE cases to begin with - somewhere between 4 and 6 mg/m2 daily. So in an 8kg dog I would give 2mg daily until clinical response is seen (or up to 2-3 weeks) then drop to 2mg EOD.

Andy

RE: PLE

Anthony Dennison — Tue, 13 Jun 2017 08:53:32 GMT

Hi Andy,

This dog was due to start chlorambucil yesterday but presented pyrexic with abdominal pain and vomiting. This has resolved with 24 hours of fluids and analgesia, so plan on starting the chlorambucil today. Would you use 1-2mg/m2 q24hrs (the immune mediated disease dose in the formulary) or the higher doses, like 20mg/m2 q2wks?

Dog is 8kg, so body surface area is 0.404m2. For daily use, would you give a 2mg tablet EOD so it works out as 2mg/m2 q24 hours, or would you split the tablet?

There is ascites and intestinal thickness is massive, so planning on giving some diuretics to reduce this down, and then will discharge on RC Anallergenic.

RE: PLE

Anthony Dennison — Mon, 22 May 2017 08:52:27 GMT

[quote user="Andrew Kent"]Most dogs with PLE will require some life-long therapy - that might be drugs, occasionally it might be diet. Are you using a decent hydrolysed novel protein diet like Purina HA or RC Hypoallergenic?[/quote]

I did put him on RC Gastrointestinal, but he's switched off it now (which may be part of the problem - I wasn't too annoyed because clinically he appeared better!). Thanks for the advice, I'll look at getting things started this week.

RE: PLE

Andrew Kent — Sat, 20 May 2017 13:06:08 GMT

I do use budesonide occasionally but find it a bit hit and miss, its more affordable now as available from Summit so is definitely one to consider.

But in some dogs it seems less effective, and in some dogs seems to have as many adverse effects as pred so there are no guarantees with it.

I tend to reach for it in dogs that are dependent on high doses of steroids and either don't tolerate or can't afford another option.

Andy

RE: PLE

Utlendigur — Sat, 20 May 2017 12:02:25 GMT

[quote user="Andrew Kent"]PLE cases can be really tricky as they often require really high steroid doses and, even then, the proteins will often remain subnormal. But with high steroid doses the cachectic side effects can be troublesome to the quality of life[/quote]

Have you had any cases where budesonide worked?

RE: PLE

Andrew Kent — Sat, 20 May 2017 11:57:12 GMT

Probably..... the only worry is that some dogs become less responsive to treatment if they go out of remission and you risk a further fall in the albumin.

Most dogs with PLE will require some life-long therapy - that might be drugs, occasionally it might be diet. Are you using a decent hydrolysed novel protein diet like Purina HA or RC Hypoallergenic?

Andy

RE: PLE

Anthony Dennison — Sat, 20 May 2017 10:16:37 GMT

Thanks Andy, that's very useful. The dog is due it's vaccines and is currently at the end of tapering (5mg EOD), so I'll vaccinate him then start everything back, adding in some chlorambucil. That'll be ok won't it?

RE: PLE

Andrew Kent — Fri, 19 May 2017 20:20:43 GMT

Hi Anthony,

PLE cases can be really tricky as they often require really high steroid doses and, even then, the proteins will often remain subnormal. But with high steroid doses the cachectic side effects can be troublesome to the quality of life.

For that reason I tend to use combinations of immunosuppressants in PLE cases to enable lower steroid doses. There is also some evidence that combinations lead to better survival.

So I would add either ciclosporin or chlorambucil to your pred then continue your pred taper.

Andy