The Berner-l on Autoimmune Polyarthritis

BERNER-L Digest 3830

Subject: Immune mediated polyarthritis (IMPA) Date: Fri, 14 Jun 2002 08:39:18 EDT From: To:,

My Berner who is a year and eight months has been diagnosised with this >horrible disease. She is currently on Prednisone and Doxycycline. (pending >results of ticke borne disease) >Any information re PIM would be greatly appreciated. Cause, Cure, Genetic, >etc...

Hi Jonelle,

IMPA is a pretty big topic, but I'll try to summary what I've learned about it since my 6-1/2 y.o. bitch was diagnosed with it last July.

About the best discussion of IMPA I've seen is the article under the heading "Polyarthritis, Nonerosive, Immune-Mediated" in the book "The 5 Minute Veterinary Consult". If you can get your hands on a copy, it will give you pretty a good leg up on understanding the the extent that the medical community understands the disease.

Depending on who you talk to and at what point in time, you'll hear IMPA intertwined with SLE (Systemic Lupus Erythematosus). It's unclear whether IMPA is a presentation of SLE, related to SLE, a precursor of SLE, or a totally separate disease...but it is clear that what initially presents as IMPA (inflamed joints) can end up as a systemic auto-immune disease wherein the body attacks any or all parts of itself.

The cause of IMPA is unknown, however it has been associated with gastrointestinal disease, neoplasia (cancer), urinary tract infection, periodontitis, bacterial endocarditis, heartworm disease, pyometra, chronic otitis (ear infection), fungal infections, and some antibiotics. While the article mentioned previously states that it is "not known to be hereditary", I personally believe that there is a genetic component to the disease in our breed.

Basically, IMPA is a diagnosis based on eliminating other possible causes of joint inflammation.

This girl had been GDC Hips-Good, Elbows-Normal, PennHIP .31/.36 at 2-1/2 yrs of age. Hocks and stifles were xrayed by my vet prior to the 'crash' that brought us to Tufts so from the start we were reasonably sure we weren't dealing with the typical osteoarthritis.

The workup for my girl was done by Tufts U. and included:

Extensive tick panels, including Lyme disease, RMSF,and relatively rare varieties of ehrlichia.

Metastasis Screen (series of xrays looking for cancer).

Comprehensive bloodwork.

(4) Joint taps.

ANA test (Looks for anti-nucleaic antibodies which indicates an auto-immune basis for the problem, however, the test results can be affected by both antibiotics and steroids...either or both of which have usually been administered by the time the ANA test is done.)

Treatment protocols and where we are now will follow in another post.



Subject: IMPA-Treatments Date: Fri, 14 Jun 2002 12:38:41 EDT From: To:,

The textbook treatment for IMPA is a course of prednisone at full dose for 10-14 days, then tapered down...hopefully to the point where the dog is clinically normal, synovial fluid is normal, and the dog is considered to be in remission, and is off the meds.

Some dogs don't tolerate pred well or, the pred alone doesn't result in resolution of clinical symptoms and normal which cases cytotoxic drugs, typically immuran, are substituted or added to the prednisone. Drug therapy usually continues for a period of months during which dogs must be closely monitored for serious side effects. If/when remission is achieved and drug therapy ceased, the recurrence rate is appx 30%-50%.

Following this protocol, I have known Bernese to live with the disease from middle age until they had to be put to rest at 9 years due to rear end ataxia. One of these (2) girls was maintained on a continuous low dose of pred, the other was on and off again relatively quickly throughout her life.

I have also know Bernese to crash big time when weaned off the meds and be lost when drugs failed to get the disease back under control. The potential is there for IMPA to 'go systemic' and erupt in organs as diverse as the kidneys and skin or for the dog to suddenly experience hemolytic anemia.

I've also known dogs that were lost due to the side affects of the meds necessary to keep the disease under control. Some dogs require high enough doses of steroids and/or cytotoxins to cause irrepairble damage to the liver, kidneys, or bone marrow. Bone and muscle loss significant enough to seriously impact quality of life is typical for dogs requiring long term treatment at higher than minimal doses.

All of these possibilities should be discussed and weighed when discussing a treatment plan with your vet.

My choice was to utilize the experience and investigation into complimentary therapies done by a friend of mine ALONG with the clinical work and input of my regular (allopathic) vet. Thankfully my vet was willing to go along with my wishes provided I understood that it was on my responsibility.

My bitch came home from Tufts on 40mg pred/day. We kept her on that alone for several days...both for the quick knock down pred provides to get things under control, and to allow time for a regimen of complimentary supplements to be worked out and arrive along with a prednisone alternative.

By the end of the first week, I started phasing off the pred and on to a product called natural hydrocortisone (NH). By the end of the second week, my girl was on the NH a dosage equivalent to appx 32 mg of pred. The supplier of the NH claims that the product is molecularly the same as the glucocorticoid produced by the body and that it's metabolized far more completely than prednisone...thereby not leaving the toxic metabolites behind that put so much stress on the liver to eliminate. How true this claim is, I don't perception based on my dog is that many of the side affects are similar in nature but greatly reduced in degree with the NH vs the pred.

In addition to the NH, my bitch is on a diet and regimen of supplements designed to support a body dealing with chronic disease, address the disease itself, and to abbrogate the negative effects of the meds and supps.

One underlying premise is that dogs with chronic diseases tend not to absorb and utilize nutrients as readily as healthy dogs. To address this aspect, she was changed from the 'premium' kibble I'd been feeding to a 'boutique' kibble that has an extremely high percentage of meat as the protein source and we added a nutrient supplement from the same company. Pureed fresh fruits and vegetables are added to meals and probiotics are given before the meal to promote digestion and absorption. Also added are a B Complex vitamin and calcium (because steroids leach calcium from the body).

EFAs and anti-oxidents are added via fish oil, flax seed oil, Vit E, and Ester C.

Both chronic disease and steroids can take a toll on the liver so 'detox' is supported with the addition of ALA, milk thistle, and an Ayrvedic herbal product.

IMPA reflects an immune system in overdrive so several supplements are used to moderate it, including: MSM (also anti-inflammatory), colostrum, lactoferrin w/ colostrum, and Moducare.

Glucocorticoids, whether synthetic or 'natural', result in some degree of muscle wasting. This has been greatly lessened since the addition (last fall) of curcumin to the regimen.

DGL (from licorice extract) is given to help protect the stomach from meds and supplements that can cause irritation.

Based on my experience, I'd conclude that with the exception of the NH, dogs who are on the standard drug protocol may well benefit from any or all of these support elements. Dosage, brand, and timing of administration are all important specifics which I've not detailed. If you choose to use complimentary approaches, please do not guess...and do not believe everything the makers tell with someone who's well experienced and knowledgeable.

Next post... Status 11 months post dx -S.F.V


BERNER-L digest 3831

Subject: IMPA-Status Date: Fri, 14 Jun 2002 13:20:43 EDT From: To:,

It's been 11 months since my bitch was first diagnosed wtih IMPA. At present, she's on the same dose of NH as she was early on. I reduced the dosage one notch in late March and then watched her VERY closely for the next 6 weeks. During that time, I noticed her get progressively less waggy-tailed, less 'up', less likely to engage in play, like inclined to do a deep stretch, less excited about going tunnel for a butt scratch. She also became flatulent (daily) for the first time in her life and her nose color paled.

These changes were very subtle, yet very clear to both my husband and I... it's one of those 'listen to your dog' things. When you know them very, very, well you're often able to *see* small changes in their physique or behavior that signal what's happening before it becomes blatantly obvious and serious. To us, they added up to indicate a decline in her well being.

I upped the NH back to the previous level and have seen ALL of the items listed above resolve in the month since.

I continue to do bloodwork (CBC and Chem) every 4-6 weeks. Alk Phos has been above normal levels (indicative of liver stress) since the beginning but not into dangerous territory. All else looks good so far.

The NH is a steroid and does lower resistance to infection, reflected in my bitch by repeated UTIs. Be careful here...the usual UTI symptoms are pretty much negated by the straining, no uncontrolable piddles, no repetitious and unproductive squatting. Our best indicator of the onset of a UTI is my intact male becoming a butthead .

So, by now you're saying "ya, ya, ya...but how's the dog"?

Apart from being a bit food obsessed, Simca's terrific! She goes for a daily run in the woods, enjoys belly rubs and butt scratches, and made me very proud getting the first leg towards her CD at our regional specialty two weeks ago....the first dog show she's ever been to. We'd left home at 7:30 AM and she'd done a full morning of 'meet & greet' with all comers looking for breed information, before going into the ob ring in the afternoon. She also looks good enough to surprise several people that she was there for obedience and not the breed ring. She slept like a log all the way home but when she got out of the truck at 6 that night, there was no sign of lameness or stress. The next morning she was singing to me right on cue when it was time to head for the woods.

Honestly, my vet wants to see the NH reduced...she wasn't pleased with my decision to increase it back to the prior level. But she also respects my insights into my dog and my conscious decision to maximize quality of life...even if it may be at the expense of lifespan down the road.

Right now, I'm very pleased with where we're at. I hope I can say the same thing a year from now and a year after that, but I also know that things can change with each bloodwork report.



BERNER-L Digest 3832

Subject: Re: Treatments Date: Fri, 14 Jun 2002 16:46:48 EDT From: To:,

One item I inadvertently omitted...

I've given Cosequin DS since the beginning. Although IMPA is considered a non-erosive form of arthritis, steroids can break down can the enzymes created by inflammation. I hope to mitigate the impact of those factors by use of the Cosequin.

-Sherri V.