Chronic enteropathy in English springer: where to now?

RE: Chronic enteropathy in English springer: where to now?

jd2008 — Tue, 10 Dec 2019 21:46:40 GMT

[quote user="Elenor Walsh"]how is moose doing? i've heard some good things about VSL#3 and have started using it in some IBD cases ,but I understand it takes a couple weeks to kick in. Would be interested to hear how you are getting on with it.[/quote]

Hi Elenor,

Moose has unfortunately turned out to be a typical vet's dog! I was a little premature with my optimism in my last post as the diarrhoea returned after only a couple of days of formed stool. I ended up adding good old oxytetracycline as something of a hail Mary and it has mostly done the trick along with a low fat, low fibre single protein home cooked diet: soft, formed stool about 70% of the time and he's finally returned to his normal weight.

To be perfectly honest, I'm not sure the VSL#3 made much difference though his 60day course finished last week so I'll be interested to see if there's any deterioration off it. As he's on antibiotics again, I might even consider giving another course at some point. To be fair Andy did mention that the evidence for its use was pretty thin, to say the least but I was willing to give it a go regardless. It is not cheap though (in Australia, at least - $260 for 60 sachets) and not terribly easy to get hold of so, if funds are limited, it wouldn't be something I'd push a client to try.

My advice if you find yourself dealing with a similar, poorly responsive case is be patient and counsel the client that it can take quite some time to find a combination of medication and diet that works. I've has many patients with chronic enteropathy over the years and none has been quite as frustratingly unresponsive as Moose (typical!). Any dietary indiscretion can also have some fairly dramatic effects too - Moose got hold of just a few cherries off our fruit trees and his diarrhoea returned with a vengeance within a matter of hours.

Current regime for Moose at the moment is: home cooked diet (kangaroo, white rice, walnut oil, pet-specific omega 3 oil, Balance-IT supplement), cyclosporine 5mg/kg sid (recently reduced down from bid), prednisolone 0.5mg/kg eod, oxytetracycline 10mg/kg bid, B12 1000mcg sid

RE: Chronic enteropathy in English springer: where to now?

Elenor Walsh — Mon, 09 Dec 2019 16:21:28 GMT

[quote user="jd2008"]

**Edited to add: Andy had suggested elsewhere trialling VSL#3 (a probiotic) and Moose is currently halfway through an initial 60 day course of this. Current meds are: Prednisolone 0.5mg/kg sid, Cyclosporine 5mg/kg bid, VSL#3 1 sachet daily, Vit B12 1000mcg/day.

[/quote]

how is moose doing? i've heard some good things about VSL#3 and have started using it in some IBD cases ,but I understand it takes a couple weeks to kick in. Would be interested to hear how you are getting on with it.

RE: Chronic enteropathy in English springer: where to now?

Anthony Dennison — Thu, 28 Nov 2019 09:47:41 GMT

[quote user="Sarah Keir"]Chlorambucil is good in chronic enteropathies - would the RSPCA allow that? (I am assuming you have already done the usual rule outs, checked B12 levels etc)[/quote]

Yes, had a limited work up due to financial constraints set by RSPCA but as it's a case not as limited as it could be.

RE: Chronic enteropathy in English springer: where to now?

Sarah Keir — Wed, 27 Nov 2019 09:34:09 GMT

[quote user="Anthony Dennison"]

Just adding on to this - currently dealing with an RSPCA case dog with probable IBD/chronic enteropathy. Been on Preds for 2 weeks now and not making a scrap of difference. What sort of dose is recommended? I've read a dose of 1.5mg/m^2 EOD but this would work out as half a 2mg tablet which wouldn't be feasible. Don't think the RSPCA will stretch to cyclosporine currently!

[/quote]

1mg prednisolone tablets are available

Chlorambucil is good in chronic enteropathies - would the RSPCA allow that? (I am assuming you have already done the usual rule outs, checked B12 levels etc)

RE: Chronic enteropathy in English springer: where to now?

Thomas Johnson — Wed, 27 Nov 2019 08:48:00 GMT

[quote user="Anthony Dennison"]

[/quote]

I think I've read that with cats with lymphoma where the recommended dose would mean splitting the tablet you can give them further apart, so with your dog you could consider giving one tablet every four days? It might be worth speaking to an oncologist as they would have the most experience of the best way to dose it.

RE: Chronic enteropathy in English springer: where to now?

Anthony Dennison — Thu, 21 Nov 2019 13:40:53 GMT

RE: Chronic enteropathy in English springer: where to now?

jd2008 — Wed, 06 Nov 2019 07:27:45 GMT

Hi again all,

Just an update in case it's of interest:

I started Moose on Chlorambucil and tapered the pred down. The improvement in his demeanour with the reduced pred dose was marked. He's currently tolerating 0.5mg/kg/day so I've left it at that on the off chance it's doing some good at this lowish dose.

He was on chlorambucil for 3 weeks with little, if any, effect - still continued diarrhoea and some further weight loss (another 0.5kg over those 3 weeks). In the meantime I changed his diet to a very low fat one (had to be home cooked due to his reactions to protein sources in commercial low fat diets. Thank heavens for Balance IT -I wouldn't have known where to start otherwise). The diet change was based purely on a suspicion that he wasn't digesting fat well. His faeces smelled strongly of rancid fat and he had dramatic borborygmus, flatulence and palpable hypermotility. This all improved markedly after the diet change.

Based on all this, I was strongly suspicious he was heading into PLE/lympohangiectasia territory. I asked the local clinic to draw bloods last week for albumin, cholesterol, iCa, coags, repeat TLI(and free T4 and cortisol to cover anything I'd missed along the way) when they checked his post-chlorambucil haematology. I've attached the results (PDF edited to remove as much extraneous info as possible). I'm genuinely staggered/baffled at his essentially normal haematology after 3 weeks on chlorambucil and also very pleasantly surprised that his albumin is normal. The ALT isn't the best, though.

I made the decision at the weekend to swap him from chlorambucil to cyclosporine 5mg/kg bid and yesterday he passed his first formed stool in 5 weeks so I think we might have finally hit on a suitable treatment regime (unless I'm missing something - all and any suggestions welcome). I'm not sure whether at any point it will be worth the risk of trying to get him back on a commercial diet -home cooking is time consuming and remarkably expensive!

Thanks again for all the input to my initial post, it is fair to say I was in a bit of a state about where to go next with Moose and your advice and suggestions helped enormously. Thank you!

Jane

RE: Chronic enteropathy in English springer: where to now?

Anthony Dennison — Tue, 08 Oct 2019 15:32:48 GMT

I'd agree with Andy. Chlorambucil does have a beneficial effect in these cases if prednisolone has poor side effects. Would methylprednisolone have the same effect?

RE: Chronic enteropathy in English springer: where to now?

jd2008 — Sat, 05 Oct 2019 22:05:08 GMT

Hi Andy,

[quote user="Andrew Kent"]You will likely have seen my reply elsewhere so won't reply twice but largely agree with Ben's thoughts here[/quote]

Yes and thank you. I have to say, being able to get such rapid input from experts such as yourself and Ben has been wonderful and reassuring. In previous clinical roles I've been able to happily outsource all the decision-making for my own dogs to my colleagues (and most recently it was the various specialist departments in a veterinary teaching hospital, so I was rather spoiled!) so going it alone in this instance, so to speak, has been a bit nerve-wracking!

Warmest thanks again.

Jane

RE: Chronic enteropathy in English springer: where to now?

jd2008 — Sat, 05 Oct 2019 21:57:01 GMT

Hi Ben,

Many thanks for your reply - all very helpful indeed and I do hope your dog is well and truly on the mend now.

[quote user="Ben Safrany"]Let us know the latest B12, when did you most recently check his albumin?[/quote].

Albumin was last checked in May. The blood for repeat B12 was drawn on Thursday so, if I call tomorrow I might be in time to ask them to run albumin on that sample too. Will certainly post the results when they come in.

[quote user="Ben Safrany"]I would recommend a fenbendazole treatment trial (3 days at 50mg/kg) just to be absolutely thorough.[/quote]

I have wanted to do this since May but an adult dog formulation isn't available in Australia. To do this I'd have to buy a litre of the 10% solution and dose him with that. Having said that, I'm very happy to give it a go if you think it's worthwhile.

[quote user="Ben Safrany"]I would consider an additional immunosuppressive to facilitate dropping his pred further, there is evidence to support either chlorambucil (4-6mg/m2 SID initially, tapering to EOD) or cyclosporine (5mg/kg BID initially), it would be reasonable to choose based on cost/availability.[/quote]

Yes, that's what I was thinking so it's good to have that confirmed. Cost and availability aren't an issue - though I still wince at the price of Atopica! - but the practicalities of repeated bloods for monitoring if I start him on chlorambucil might be.

I only restarted the pred 24 hours ago so diarrhoea not under control yet but not as watery this morning as yesterday. I'll make a decision re. chorambucil vs cyclosporin and get him started on that as suggested and will certainly keep you posted.

Thanks again,

Jane

RE: Chronic enteropathy in English springer: where to now?

Andrew Kent — Sat, 05 Oct 2019 19:57:34 GMT

Hi Jane,

You will likely have seen my reply elsewhere so won't reply twice but largely agree with Ben's thoughts here.

[quote user="Ben Safrany"]Would be keen to hear others' experience with budesonide in similar cases.[/quote]

I've rarely been impressed with budesonide or felt it brought much to the party over prednisolone. The time I consider it is in patients who are very steroid responsive but are not helped (ie we can't get the dose lower) with the addition of a second immunosuppressant and perhaps have significant adverse effects of that steroid.

So in this case I would favour chlorambucil or ciclosporin.

Andy

RE: Chronic enteropathy in English springer: where to now?

Ben Safrany — Sat, 05 Oct 2019 16:36:35 GMT

[quote user="Emily Rainbow"]

Have you ever checked a basal cortisol pre-steroids?

Thinking trying to rule out addisons (atypical or typical)?

[/quote]

I think checking a basal cortisol and/or ACTH stimulation test is worthwhile in cases with chronic GI signs. However, I would expect a prednisolone dose of less than 1mg/kg to control the clinical signs if this were Addison's, so think this is less likely.

[quote user="niall morton"]Budesonide worth a try??[/quote]

I've had limited experience with budesonide, in the few cases I've tried it in I haven't found a dramatic reduction in steroid side effects compared with pred. In principle it could be a great alternative for these cases. Dye and others (2013) did a randomised control trial comparing pred and budesonide in dogs with IBD and didn't find a significant difference in remission rates or adverse effects between groups, although numerically there was a reduction in severe side effects in the budesonide group. Other studies have shown suppression of the pituitary adrenocortical axis in dogs on budesonide.

It could be worth trying, I would be keen to try and get on top of the signs and aim to get Moose into remission first. Given that he isn't controlled at 1mg/kg I'm not sure if switching to budesonide alone would be sufficient. Would be keen to hear others' experience with budesonide in similar cases.

https://onlinelibrary.wiley.com/doi/full/10.1111/jvim.12195

RE: Chronic enteropathy in English springer: where to now?

niall morton — Sat, 05 Oct 2019 15:37:27 GMT

Budesonide worth a try??

RE: Chronic enteropathy in English springer: where to now?

Emily Rainbow — Sat, 05 Oct 2019 15:17:45 GMT

Have you ever checked a basal cortisol pre-steroids?

Thinking trying to rule out addisons (atypical or typical)?

RE: Chronic enteropathy in English springer: where to now?

Ben Safrany — Sat, 05 Oct 2019 08:21:55 GMT

Hi Jane,

I'm really sorry to hear your own dog has not been well. I think you've taken a really logical approach to his case so far. I know what you mean about struggling to think rationally when it's your own dog in question, my dog's just on the mend from a particularly nasty episode of acute haemorrhagic diarrhoea syndrome.

It sounds most likely that Moose has steroid-responsive IBD (which was previously diet responsive), but the dose of steroid needed to control his signs is too high to avoid steroid-related side effects. You could have done biopsies to confirm this but I think it's perfectly reasonable to go to treatment without. We can't rule out lymphoma at this stage, but his response to initial treatment is encouraging.

Let us know the latest B12, when did you most recently check his albumin? Might be worth asking for this to be checked on the latest sample too.

I would recommend a fenbendazole treatment trial (3 days at 50mg/kg) just to be absolutely thorough. I would consider an additional immunosuppressive to facilitate dropping his pred further, there is evidence to support either chlorambucil (4-6mg/m2 SID initially, tapering to EOD) or cyclosporine (5mg/kg BID initially), it would be reasonable to choose based on cost/availability.

Are his signs controlled again now you're back up to 2mg/kg pred? If so I would try and keep him there for 2 weeks before tapering to 1.5mg/kg while you add a second-line drug. I would recommend dropping the metro back to 10mg/kg in the meantime as increasing the dose hasn't helped. I would try and get him off this soon, but as he's quite complicated would try and only change one thing at a time.

For what it's worth I don't think your pred tapering was unreasonable, I wouldn't consider this a particularly rapid taper especially with the steroid side effects so stop beating yourself up!

I hope some of this is helpful, keep us posted with his progress.

Best wishes,

Ben