Thursday, November 24, 2016

A quick update on Stella: Lameness has re appeared. My thoughts.

I had to get a few thing down on paper for Stella's next vet visit so here goes.  This is random and all over the place, but I have to get my thoughts out on paper before they drive me nuts, plus i can print this off and take it to my vet.

Just a brief reminder for me and you, Stella came up lame sunday night on a front leg.  This is similar to how the flare up started last time.  It started with a fever, lameness on a front leg and then shifting lameness to the back leg.  It ended up with continuous fever and lameness on three legs.  At first, KSU vet med said "athletic injury" but when it ended up being three legs involved, the diagnosis was changed to flare up and she was put back on 20 mg of pred a day.  Currently we are in a 10 mg every other day program.  The lameness started post a run sunday (11/20), got a better after getting 10 mg of steroids that night, came back a little bit less when she didn't get her steroid as part of her taper. Had a day where she was completely fine.  Then it presented as rear leg lameness tonight, after being perfectly fine this morning (11/24) AND after not receiving her 10 mg of steriod the night before, per her taper.

 So we have a couple of scenarios going on here as I see it: 

1.  The steriods are covering up pain due to damage in her joints (do steriods cover up pain?  if not this theory is not valid), so when they get to a low enough dose in her system, the pain of the damage/inflammation starts back.  The pain is always there and will always be there unless we can cover it with some dose of steroid.  Maybe 5 mg a day or 2.5 mg a day instead of the every other day?  

2.  Once she gets to a low enough dose, the disease starts attacking her joints again and is active.  We will never be able to go below 10 mg pred and the combo of pred and cyclosporine is not doing the intended job.  Maybe discontinue the cyclosporine???  Maybe try a lower dose of steroid every day for some time?

3. She has erosive IMPA and damage is done which is kind of like #1 so maybe this isn't a number 3. Would we have a completely different treatment plan including joint supplements and NSAIDS?  If it isn't the disease flaring up, then can we discontinue the pred altogether?

Is there anyway to see joint damage in a dog other than an MRI?  If it is indeed joint damage versus active disease, would we take a different route of treatment?  Do we need to take a synovial biopsy to see changes there?  An article I read said that x-rays are sometimes hard to see joint damage, so that a synovial biopsy is better way to see joint changes.  From what I can tell, synovial biopsies are more about biopysing the lining of the joint and not the fluid itself.  She has had multiple joint taps to diagnose and then to determine if she was in remission for step down of pred.

She is lame on her back left leg again and I am pretty sure this is the same leg she was lame on before (i double checked her records and yes that is the same leg).    This time however, she is not lethargic and is not presently running a fever like the last time when she flared.  The last time she flared, she had been on the 10 mg every other day for not even a week, maybe a few days before she spiked a fever.  Thus far this time, she has been fever free and she had gone almost 2 weeks before this started.  At the previous flare up, she had been already running  mileage with long runs of 6 or 7 miles when we tapered her down to 10 mg.  She had had quite a long slow taper from walking to walk running to just running before any lameness or flare up.  My brain is trying to get around why the flare up or pain seems to always happen when we get down to the 10 mg every other day dosage, especially when she was running quite a bit previously when we stepped down to 10 mg every other day.  

So many questions.  So many thoughts.  SO much research to do.  My vet at KSU has recommended she stay at the 10 mg every other day dosage till I see him december 16th.  She is back on a no exercise protocol and is suppose to take codeine for the pain.  She had codeine now about 4  hours ago, and she is still limping pretty badly on that rear leg.  She did get steriods tonight, so I am hoping that she follows the pattern and is fine tomorrow morning.  That is still very puzzling and very indicative to me that she needs to be on every day steroids of some level of steriods still for any of the scenarios that I have mentioned.  This is going to be a very long wait till we see KSU again but I am glad that the vet is at least responding via email.  

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