Treatment For Protein Losing Enteropathy

[Guest OPointyDog]

Our 6-year-old female greyhound Zoe was diagnosed with Protein Losing Enteropathy in April.

 

Backstory: Zoe had been having diarrhea on and off, but nothing serious, and then I came home from work one day and she looked like she had swallowed a watermelon she was so swollen. Got her to the vet, and the fluid was ascites. They did bloodwork, and found her total protein levels were low, as was the albumin, and the vet suspected PLE. They did an x-ray of her heart, and drew more blood (B12 level and some more detailed liver values). B12 was low, so we started supplementing. Heart appeared normal. Liver values were normal. Started her on Tylan powder and a bland, low fat diet, and got an appointment to go to a specialist.

 

Within 5 days, she had cleared the ascites and the diarrhea was improved, but she was still lethargic, and had lost about 7 lbs from her normal weight (70lbs to 63). We took her to an internal medicine specialist, and they did an ultrasound, and then scheduled an endoscopy. Ultrasound did not show any masses, but did reveal several blood clots, including a large one in her portal vein that seemed to be clearing. That's likely what caused the ascites. Endoscopy revealed that the root cause of the PLE is inflammatory bowel disease; moderate thickening and inflammation in the upper intestines, but no masses or lesions and biopsies revealed no cancer. (Whew!)

 

So about 5 weeks ago, she started on prednisone and a hypoallergenic diet. Here's what she's currently getting:

 

Prednisone, 20 mg (once/daily)

Tylan Powder, 1/4 tsp (twice/daily)

20mg aspirin, 1 daily (to prevent clotting)

B12 shots (every other week)

 

Royal Canin Hypoallergenic dry food (4 cups/day) + canned of the same

Hills Hypoallergenic treats

Dried banana chips

 

We had her bloodwork repeated last week, and everything was normal except total protein (now 4.1) and albumin (now 2.2). I've read online that greyhound values for total protein run lower, but hers is still below the normal range.

 

Zoe has regained her energy level (and then some!) and is eating and pooping normally. She's drinking more than normal and having some accidents, but I think that's the prednisone. She has gained 2.5 lbs, and seems to be gaining about 0.5 lbs per week (currently 65.5). It was hell at first, but she does seem to be tolerating the prednisone reasonably well at this point.

 

The internal medicine specialist seemed to think that if Zoe were going to return to normal values on the current medicines, she would have done it by now and suggested adding either chlorambusil or cyclosporine to her treatment (both are immunosuppressants). My feeling was that we didn't know if her values had plateaued yet, and I'd like to keep things the same and test again in a month. For now we're waiting - am I being too conservative?

 

Anybody had greyhounds with PLE on chlorambusil or cyclosporine? The vet specialist seemed to prefer the first, as it was easier to dose and was generally better tolerated.

 

Any thoughts or suggestions on long-term management of PLE are appreciated!

Edited June 15, 2016 by OPointyDog

[tbhounds]

Sounds like your hound is being treated properly. The only thing that I would ask them is if you can use budesonide rather than pred.

As you know pred causes all sort of side effects-pu/pd (excessive urination and drinking), muscle loss, panting, pacing, increased appetite-and what concerns me the most-increased chance of clotting. The Budesonide primarily stays within the GI tract reducing the side effects seen from pred.

If your vet doesn't want to switch out the pred I would also inquire about giving azathioprine with the pred.

Chlorambucil is generally well tolerated and isn't too expensive (I ordered it for one of my girls from SBH in Worthington, OH)-cyclosporine can be pretty hard on their tummies.

Not sure if this helped you at all ;-)

[Guest OPointyDog]

Yes, I asked for budesonide instead of pred when it was first prescribed - we have a cat on budesonide with many fewer side effects than when she was on pred, so I certainly agree. The specialist was pretty insistent that pred was the way to go. Maybe I can get our local vet to talk to her about why she doesn't want to switch it out, since I haven't gotten a great answer.

 

I haven't heard of azathioprine. Is that an alternative to the other two immunosuppressants?

 

Definitely helpful, thank you. Did your girl have PLE? I'm hesitant to ask what the typical prognosis is for long term management. Both vets have hedged a bit when I ask about it and say it varies a lot, depending on how the dog responds to treatment.

[Guest Loves4Greyz]

We had a 5 month ordeal with one of our pups...diarrhea and occasional vomiting We had ultrasound, endoscopy, colonoscopy and lots of blood work done. Helicobacter pyloris and IBD were diagnosed. We were supposed to put him on a low fat diet but got to the point that we gave him whatever he would tolerate. He was on metronidazole, 50 mg of prednisone, and prilosec along with B 12 injections once a week. When he kept losing weight he was put on cyclosporine. It didn't help and he hated taking it. Hope that your pup improves.

[tbhounds]

Yes, I asked for budesonide instead of pred when it was first prescribed - we have a cat on budesonide with many fewer side effects than when she was on pred, so I certainly agree. The specialist was pretty insistent that pred was the way to go. Maybe I can get our local vet to talk to her about why she doesn't want to switch it out, since I haven't gotten a great answer.

 

I haven't heard of azathioprine. Is that an alternative to the other two immunosuppressants?

 

Definitely helpful, thank you. Did your girl have PLE? I'm hesitant to ask what the typical prognosis is for long term management. Both vets have hedged a bit when I ask about it and say it varies a lot, depending on how the dog responds to treatment.

I had a hound that had severe IBD. He was on a pleather of meds. He did do pretty well and seemed stable for about 2 years-sadly the IBD morphed to cancer (adenocarcinoma-very aggressive) and I had to let him go.

The azithroprine is an immune suppressant med-it usually will allow you to use a lower pred dose. Dr Couto rec in the past for my boy.

[Guest OPointyDog]

Update!

 

Three months later, Zoe is still doing pretty well clinically - no diarrhea, maintaining her weight (now at her normal weight of 68-70lbs) and energetic (for a greyhound). Her blood protein levels have gone up and down a bit - between 4.6 and 5.2, so at the low end of normal. We tried dropping her down to 15mg of pred daily, but her blood protein dropped, so we moved it back to 20mg.

 

Then last week she developed spay incontinence - lots of accidents while she's sleeping in the evening. Interestingly, none overnight or when she's crated during the day - just in the evening. She's been drinking more sometimes, but not always, and I'm not sure if increased drinking is the only cause, and if the increase is related to the pred (which she's been on for months now) or if something new is happening. Or if this is just ordinary spay incontinence and unrelated to her PLE.

 

The vet initially recommended Proin, but then we realized that it has two problems 1) can lead to bleeding problems when given with aspirin, and 2) it has flavorings in it that may impact her hypoallergenic diet. So I asked about alternatives, and we contacted the internal medicine specialist who saw her in May. My thought was to switch Zoe to budesonide to see if getting her off the pred would help, and so that's what we're doing now, is transitioning to budesonide.

 

The vet prescribed 2mg of budesonide daily - is that typical for PLE cases? Anyone know? Seems low to me, since our 8lb cat is on 1mg every other day....

 

Anyone else dealt with PLE and incontinence?

[tbhounds]

No proin!!!!! Raises blood pressure-can cause strokes-not want you want with your PLE hound. I would see if she drinks less (and she will) once on the budesonide-perhaps that will resolve the urinary incontintence. If you find you still need to medicate then I would try DES or incurin. The budesonide dose does sound low -I had my boy on 3mg but, he I'm sure he was bigger than your girl so perhaps your vet adjusted the dosage appropriately.

[Guest OPointyDog]

Thanks, yes, that's our current plan is to see if the switch to budesonide alone will resolve the incontinence. If not, then I'll see if we can try the other two medications you mentioned. Thank you!

[cello]

Our girl Lady was diagnosed with PLE three and a half years ago at age 8.5. She had no outward symptoms, the low blood protein was discovered during routine pre-op blood work before a dental. Thank goodness they caught it, or we probably would have lost her during the extractions.

Immediately started seeing an Internal Medicine Vet at the specialty hospital. Had an ultrasound and an endoscopy done that diagnosed her PLE.

She started on 40mg of Prednisone every day, and gradually tapered that off to where now she only gets 10mg three times a week. We use Tylan powder if she has a diarrhea flareup. She takes a Pepcid everyday, along with Mirtazapine appetite stimulant.

She has been on an ultra low fat diet since her diagnosis. She strongly resists the low fat kibble. She was literally starving herself to death. So desperate times require desperate measures! Turns out plain boiled pasta has almost zero fat, and plenty of calories! As does plain boiled skinless, boneless chicken breasts! So she now eats one cup of Royal Canin Low Fat Gastrointestinal kibble, with two cups of pasta, and half a cup of chicken twice a day. We sometimes also use the canned form of the kibble to make things interesting. We have to keep switching things around to make her feel like she is getting something new to eat. Hard to due when you only have four ingredients to work with!. OH - plus a couple of hypoallergenic cookies each evening. I smash them up into small bits and add them to whatever food she hasn't finished yet that day.

 

Her weight dropped from 70 pounds to close to 60 - she was nothing but skin and bones. She is back up to 69 pounds and looks awesome. Specialist says she looks like a "Million Bucks!"

 

Her current protein levels are holding steady at the bottom end of normal at 5.4. 2.7 for albumin and 2.7 for globulin. If you look at Dr. Couto's chart for Greyhounds, these are actually pretty good values.

 

When this all went down 3.5 years ago, we had four Greyhounds. Our big goal was to get Lady to her 10th birthday. Now the other three have all passed away, and Lady will turn 12 in four more weeks! You just never know how things will play out. Right now, Lady is still greiving over the loss of her packmates - two in the last four months, and it is effecting her eating.

 

I wish you all the best, and hope that Lady's success story will give you long term hope.

 

Carol Ann & Lady.

 

P.S. This is a photo of Lady taken last week.

 

[Guest OPointyDog]

Wow, Carol! That is amazing! Lady looks terrific - what a gorgeous girl!

 

Thank you so much for posting Lady's story - I am so glad to know that you have been able to maintain her long-term. It gives me hope that maybe Zoe has a few more years, at least.

 

So far she's got a really good appetite, so I haven't had to add anything to her food. My guess is that the pred helps with that. She eats the Royal Canin hypoallergenic food, 2 cups of dry mixed with part of a can of wet, twice a day, and that has maintained her weight. I did add pepsid to her regimen recently, since she was having trouble with her stomach.

 

Here's a photo of Zoe:

 

Zoe

[cello]

Zoe is a gorgeous girl!

 

You are lucky that she is eating. Our vet says that she has never had a dog on pred with no appetite until Lady!

 

Good luck. Feel free to message me anytime you have questions.

 

Carol Ann.