Mikey Man update (its been a while)...

[Traci]

I would think the azathioprine would be more of an insult than the pred.....pred generally doesn't produce lethargy or nausea (that I am aware of)....if anything, the pred should be making him more comfortable, reducing inflammation and increasing his appetite to some degree. Maybe ask your vet about the azathioprine dose. Also, do you give his medications near mealtime, give them sporadically or are they given at a certain time each day, etc?

[JMM]

Hmmmm...more to think about...

I give his carafate at set times to be sure it is separated from his other meds and so that it is spread out over the day. His morning meds are metronidazole, cisapride, lactulose, and pred (EOD now). I give his metro, cisapride, and lactulose an hour after his AM carafate and wait to get a little food in him for the pred (he is allowed a small piece of cheese). Mid-day he has denosyl and an hour later carafate. Sometimes I hold the denosyl till later in the day if he eats mid-day. In the evening, I give the meds and feed him, but wait till he eats to give his lactulose as that is when he tends to have problems (and he eats more consistently at night than in the AM or during the day). I give the azathioprine at night when he is more likely to eat.

[Traci]

More q's.....is the cisapride and lactulose given for constipation issues or for maintenance to keep the stools consistent? Am wondering if there is possibly a conflict between those and the flagyl and wondering if the flagyl could be either reduced or ceased altogether sometime.

The carafate can be given anytime, with or without food, it is a very mild medication. (same as with denosyl)

The pred of course, should ideally be given twice a day, morning and night for the most beneficial effect, depending on the dose. Smaller doses can be given once a day, or in this case, EOD, once.

One more thought, the nausea could be dehydration....do you ever give him sub-q fluids? Ask your vet about this, they might be a good pick-me-up for him on days he seems so nauseated or vomiting.

These are just my thoughts, JMM, but maybe run a few of these ideas by your vet.

[JMM]

Traci, I keep a list of questions for my vet...he's great and will discuss any of them with Mikey's internist if I don't ask her myself. I love suggestions. You've had some great suggestions that I've brought up with my vets. BTW, we should hear from the UK next week or the week after. Their path department at the university closed for winter break right after the slides arrived. I have one more set of slides and haven't decided who to send them to yet. Maybe Illinois.

The cisapride is given for motility effects for his vomiting. The lactulose is for hepatic encephalopathy. The metronidazole is for diarrhea. When we stop it, he immediately gets bloody diarrhea. When on it, he still has intermittent diarrhea, but only once or twice a day. He tolerates the metronidazole better than amoxicillin as well, so we use that as his GI/liver antibiotic. The lactulose hasn't seemed to effect the consistency of his stool much at all. When he has a normal stool, it is nice and soft as it should be on lactulose.

You had also mentioned a feeding tube waaaaaay back. I brought this up again with Mikey's internist since we decided the pred is not a great solution for him. We decided that if he gets down to under 5 lbs and it not eating but is doing well as far as vomiting goes, that would be a good solution. If he's vomiting, we wouldn't do it. Right now he is not vomiting much at all...maybe once a week!

He is much better today, his first day off of pred. He seems very comfortable and has done some barking and trying to steal tissues!

[Traci]

Well, it seems you've ruled out virtually everything that could attribute to the bloody diarrhea...however, stress and diet would be at the top of the list to re-evaluate (pending slide results). Were you ever able to talk your vet into consulting with a nutritionist to form a diet for Mikey's specific needs?

I don't think a feeding tube should be considered without first re-evaluating his diet and possibly medication adjustments here or there (the lethargy could be a combination of any of the meds, or all of them, or a combination of other things, i.e., the liver, dehydration, malabsorption, stress). Again, sub-q fluids might be helpful, and it certainly wouldn't hurt to try, so ask your vet about them.

[JMM]

We've talked about a nutrition consult...something to bring up again. With the cost of all of his medications and monitoring bloodwork, I've only done one additional thing at a time.

I forgot to answer about the SQ fluids. Mikey is very painful after even a small amount is administered. He is really a little dog and there isn't much room for them. When he is dehydrated enough to need fluids, we just put him on IV fluids during the day. It is convenient since he usually goes to work with me anyways and he doesn't stress out about it.

[JMM]

Latest e-mail from Dr. Hall...I don't know how much this really changes anything, though.


The sections have been stained and reviewed. As I said before one of the
slides was broken, but salvageable.

The report can only make conclusion on the evidence of the new sections
supplied and states:
------------------------------------------------------------------
The broken section had four gastric biopsies which have essentially normal
structure, although there is a mild eosinophilic infiltration of the lamina.

The other slide has one piece of stomach and several portions of duodenum.
In the duodenum there is a very active Peyer's patch included. The mucosa
has basically normal structure, but there is mild oedema of the LP and a
mild eosinophilic infiltrate.

Overall, there is evidence of a 'mild eosinophilic gastritis and enteritis
(duodenal)'.

There were no liver sections on the slides.
-----------------------------------------------------------------

Thus we potentially disagree slightly with the previous reports:
We also would grade the eosinophilic inflammation as mild, but did not find
evidence of mild lymphoplasmacytic gastritis and duodenitis. However, this
is a subjective description as there is no unified grading scheme.

One potential confusing factor in the original report is the mention of 'a
large dense focal aggregate of lymphocytes....'. We believe this is most
likely a normal Peyer's patch, i.e. normal lymphoid tissue, but this is not
made clear in the report.

Overall, I would agree there is mild eosinophilic gastroenteritis, but the
degree of inflammation in these biopsies would make me question whether
your dog truly as idiopathic IBD. I would more strongly suspect infection
or allergy, and would still suggest trying to remove immunosuppression
(gradually) and see what happens.

Hope this helps.

Sincerely
Ed Hall

[Traci]

It's been my thought all along that the azapriothine should be re-evaluated and the possibility of infection, but I hope you'll bring this up with your vet. You've already attempted to taper off the pred various times before (yes?), so I wonder if it would be appropriate to look closer into the azathioprine at this point. I'm aslo still wondering if even the lowest dose of pred could still be somewhat therapeutic on an intermittent basis.

Again, just my thoughts, JMM, I know you and your vets have been through this countless of times. It just seems there may perhaps be a dosing problem somewhere. Did he currently have Mikey's medication schedule to review with the slides?

[JMM]

Yes, he had Mikey's whole record including current meds and the other path report.

I am leaning towards stopping meds and seeing what happens...maybe endoscoping him again. This opinion just coincides with my feeling that we are missing something. Because of the length of times he has been on Baytril or Clavamox, it would have to be one weird infection (I discussed this with both vets...he has been on Baytril for a UTI for 6 weeks over the summer and again for 3 weeks more recently). Something just doesn't jibe.

He is feeling much, much better since the latest pred reduction.

[Traci]

If you do cease some or all of the meds, the pred needs to be tapered off, not sure about the azapriothine.

Before ceasing all of the meds, take a closer look at the current diet to try to find offending ingredients that may be causing bacterial infection (particularly if you are feeding home-cooked or any raw)