My 4 yr.old PWD Just Got Out of Intensive Care for Cell-Mediated Polyarthritis. I Need Holistic Suggestions?

Question by : My 4 yr.old PWD just got out of intensive care for cell-mediated polyarthritis. I need holistic suggestions?

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Answer by M A S
Cell-mediated Polyarthritis : Inflammatory joint diseases can be classified as infectious or immune-mediated. The immune-mediated polyarthritides are defined by (chronic) synovial inflammation, failure to identify a microbial etiology on routine culture of the synovial fluid and clinical response to immunosuppressive therapy. These diseases have common immunopathogenic features and may be subdivided based on clinical, radiographical (erosive / non-erosive types), pathological and serological parameters. Classification of the arthritides is useful for deciding on treatment and prognosis.

Immune-mediated arthritides
Erosive : Rheumatoid arthritis (RA) Polyarthritis of Greyhounds Felty’s syndrome (rheumatoid arthritis, splenomegaly, neutropenia)

Non-erosive : Idiopathic” (IPA) (type I-no associations, II-reactive, III enteropathic, IV-neoplasia related) Systemic lupus erythematosus (SLE) Vaccination-associated Polyarthritis / polymyositis (e.g., spaniel breeds) Polyarthritis / meningitis (e.g., Weimaraner, Boxer, Bernese Mountain Dog) Polyarteritis nodosa Sjogren’s syndrome Arthritis of Akita Inus Amyloidosis (Shar Peis) Lymphocytic-plasmacytic gonitis Drug-induced (e.g., trimethoprim-sulfonamide)

“Idiopathic” Polyarthritis (IPA)

Includes all those cases of inflammatory arthropathy which can not be classified into the other groups, e.g., RA or SLE (see table 1). Type I is by far the most common of all the immune-based arthropathies in the dog. The “idiopathic” type can be divided into 4 subcategories:

Type I: – Uncomplicated IPA – This type accounts for approx. 50% of all the “idiopathic” cases. The RA dogs and the IPA dogs have most immunopathological features in common, therefore, some idiopathic cases might represent an earlier or milder form of rheumatoid disease. In this type, no underlying disease can be detected.

Type II: – IPA associated with infectious disease outside the joints (reactive form) (approx. 25% of all IPA cases) Infections of the respiratory tract (incl. tonsillitis), urogenital tract, teeth, ears or skin, leishmaniasis, ehrlichiosis, borreliosis, and bacterial endocarditis have been reported in association with immune-mediated arthritis. (Borrelia, Ehrlichia and Leishmania may cause a true infective arthritis and / or immune-mediated arthritis). The infectious process might provide an antigenic source for immune complex formation.

Type III: – IPA associated with gastrointestinal disease (enteropathic form). The diseased gut may show an increased permeability to potential antigens which could stimulate the production of immune complexes. Hepatopathic arthropathies have been described as well.

Type IV: – IPA associated with neoplasia outside the joints (neoplastic form): e.g., squamous cell carcinoma, leiomyoma, mammary carcinoma, lymphoma. Neoplasia can stimulate an immune response by the host and thus the formation of circulating immune complexes.

Therapy

In IPA type II-IV treatment is primarily directed against the underlying disease if possible. In some cases analgesic/anti-inflammatory drugs or corticosteroids are indicated. In RA, IPA type I and vaccination reactions analgesics (e.g., meloxicam 0.1 mg/kg SID, carprofen 2-4 mg/kg SID, metamizole 20 mg/kg BID-TID) and eventually doxycyclin (5 mg/kg BID) are given till all test results are available. Spontaneous recovery is possible in vaccination reactions and in some dogs with IPA type I. In most cases immunosuppressive therapy with prednisolone (1 mg/kg BID) is indicated. Glucocorticoids should not be combined with NSAIDs because gastrointestinal ulceration might occur. High prednisolone doses are given for 2 weeks and then the dose is gradually reduced (approx. ¼ every 2-3 weeks) over the next months. There is generally a marked improvement within a few days, but maintenance therapy is important to prevent relapses. Constant low-dose prednisolone is sometimes necessary to keep the animal in clinical remission. Repetition of the arthrocentesis is helpful to assess response to therapy and is indicated if relapses occur.

A combination of prednisolone and cytotoxic drugs can be tried if there is insufficient response, relapse, or if severe side effects occur. There are no controlled studies to show that one cytotoxic drug is better than another. Some authors recommend cyclophosphamide (50 mg/m2 4 days/week). Side effects are sterile hemorrhagic cystitis and bone marrow suppression. If cytotoxic drugs are given a complete blood count every 1-2 weeks is indicated. If the WBC count falls below 6000/µl or the platelet count below 125,000/µl the dose should be reduced by ¼; if the WBC count falls below 5000/µl (neutrophils < 2500/µl) the drug is discontinued for 1 week and then recommenced at ½ the initial dose. Cyclophosphamide should not be used for more than 3-4 months because of increasing risk of bladder toxicity. Instead of cyclophosphamide cyclosporine (initially approx. 3 mg/kg PO BID)

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