New Diagnosis - Please help!

Epi4Dogs Foundation Inc.’s mission is the advancement of science and education relating to EPI (Exocrine Pancreatic Insufficiency), yielding useful insights and positive outcomes in better managing EPI in dogs and cats. Our goals are to support and/or collaborate with veterinary EPI research and researchers, and to promote EPI awareness by educating the general public, pet owners, pet organizations, rescue and shelter organizations, veterinary schools and veterinarians.
Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

New Diagnosis - Please help!

Post by Rapids77 » 17 Jun 2020, 11:44

Hello All
First – I’m so happy to have found this forum/site. Just browsing a bit and you all are giving me so much comfort that I might just be able to get my dog’s disease under control and save his life.
At this point though, I’m beside myself and my poor pup is so sick and I’m just so confused.
A little info:
Blu is a German Shepherd and he just turned 1 in February. He was probably around 67lbs before all of this started. We’ve had no issues with him, his eating or his pooping until the middle of May when projectile diarrhea started overnight. We were at our cabin and figured he had eaten something he shouldn’t have.

Vet diagnosed him with anaplasmosis and started on Doxycycline. He didn’t get better diarrhea continued, multiple trips back to vet, he was put on prednisone as they determined he had low blood platelets and also pain meds as he was in a ton of pain in his hind quarters. He continued to lose tons of weight and I finally had then run an EPI test.

I couldn’t wait for results and took him to the emergency vet this past Sunday. They admitted him as he was down to 48lbs. They ran a full set of labs and shockingly everything looked decent (liver, pancreas, kidneys etc.). They started IVs with fluids and all sorts of other stuff and got the poop to slow way down and turn solid. He gained 4.5 pounds between Sunday and Tuesday morning.

I went to pick him up and as I was waiting to get him original vet called with the EPI test results. His TLI is LESS than 0.1. I had the results faxed to the emergency vet who said treatment plan will be the same but had me order Pancrezyme® Powder as well. Still waiting on that.

Of course, as soon as we get home he starts in on diarrhea again and went 4 times yesterday afternoon and has had 3 cowpies already this morning.
My concern is the HUGE amount of meds he’s on from emergency vet are not a good fit now that he has this EPI diagnosis. I don’t know what questions to ask or meds to request be stopped or possibly switched and was hoping you all might have some advice. I adore this dog and want to do anything we can to save him.

Today he started getting aggressive with food (he’s been ravenous for 2 weeks and crazy about eating his poop but just today he started ripping into the dog food containers and trying to grab food out of our hands).
The emergency vet has him now on Royal Canin Veterinary Diet Gastrointestinal Low Fat. They said to only feed 5 cups per day which also seems low.
I’ll attach his current med list and the TLI results for reference and a picture of my baby when he was healthy. Thank you so much in advance for any input!
Andrea
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Shirl D.
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Posts: 86
Country: United States
State: New York

Re: New Diagnosis - Please help!

Post by Shirl D. » 17 Jun 2020, 15:26

Hi Andrea! Welcome to the forum. Blu is very handsome! Based on your information so far, you are on the right track, and we can help get you the rest of the way there. First of all, it's not at all surprising that his poops turned to diarrhea again. They will not really get better until he has the enzymes that were ordered (Pancrezyme). Without them, he cannot break down the food he eats properly to get the nutritional benefit from them. Since the food is not broken down and digested, it tends to come out as cowpies. Hopefully the enzymes will be in very soon.
There are 4 aspects to EPI that all need to be addressed. I'll go over them one at a time:
1. Enzymes - the Pancrezyme powder you are waiting for will replace the enzymes his pancreas no longer produces, and allow him to break down the food. This will help him tremendously. He will start getting proper nutrition again, so the weight loss should stop and he should start to gain. The stool should also start to firm up. FYI - I don't know what the packaging says on the Pancrezyme, but the enzymes often give directions that just don't work. To give the powdered enzymes, use a ratio of 1 teaspoon of enzyme for each cup of dry kibble (if you feed wet or raw, the ratio will be slightly less). So, if he eats 1 1/2 cups of kibble, you will use 1 1/2 teaspoons of enzymes. Mix the enzymes with lukewarm water (use enough water to coat the kibble so the enzymes are distributed evenly) and add it to the kibble. Mix it thoroughly, then let it sit for 20 minutes. The enzymes can cause mouth sores, and waiting at least 20 minutes after mixing it with the kibble tends to reduce the chance of that happening. Give it one last stir before you feed just for good measure and let him eat.
2. Food - This can be the trickiest part of the equation. EPI dogs are all different, and a food that works well with one EPI dog may not work well for another. However, there are some general guidelines that work for most EPI dogs. I know he was just started on Royal Canin Veterinary Diet Gastrointestinal Low Fat. Do you know if the vets have any other concerns or have diagnosed anything else besides EPI? If not, and they recommended this food for his EPI, my suggestion is to stop feeding it. Most EPI dogs don't do well on any prescription foods, unless they also have another issue that requires it. In theory, the food should be good, but in reality, based on the experiences of many, many EPI dogs, it doesn't work for very many of them. If he has no other digestive issues, look for a food with less than 4% fiber. Grain-free usually works pretty well for our dogs, although I know that there are now lots of concerns about grain-free foods. The best we can recommend for our EPI dogs is to find a food that has 4% fiber or less, no peas (if at all possible) or legumes, or the lowest amount you can find, and no rice (usually does not sit well with EPI dogs). Look at the Dog Food Options page under the Managing EPI tab for suggestions. Try to find a food that has most of its protein from meat sources rather than from plants. Also, there is no need to restrict the fat (unless there's another condition also). They have found that low fat food will actually inhibit EPI dogs from gaining back the weight they need to regain. Another thing I wanted to mention...once you get the enzymes so that he can actually benefit from the food, we recommend feeding 1 1/2 times the recommended daily amount on the dog food package. This will give him more calories to help him gain weight back. It is easier on their digestive system if you can break it down into multiple smaller meals, perhaps feeding him 3 or even 4 times a day instead of just 2 large meals. Every meal (actually everything he eats) needs to have enzymes added. You should do your best to not give any treats until he is stable. Any food without enzymes will continue to throw things off in his digestive tract.
3. B12 - Blu's B12 level (the cobalamin number on the test results) is in the normal range, but it is in the low range of normal. This is not good enough for our EPI dogs. He needs B12 supplementation. Our EPI dogs do best if their B12 is in the upper range of normal, above 600. Low B12 can cause a change in personality, like the food aggression you are suddenly seeing. I strongly urge you to start B12 supplements as soon as possible. This will also help with firming up his poops. There are 2 ways to supplement that both work well for most EPI dogs. One is to have a series B12 injections to get the level up, then he would need periodic injections to keep it at that level. You can find information about this on the B12 pages. Some vets will show you how to do the injections and you can do them at home to save money (instead of having to take him to the vet regularly for the shot). The other option is to get an oral B12 supplement, but it needs to have something called the intrinsic factor to be absorbed properly. The supplements I know that have the intrinsic factor are both Wonderlabs; Pet Factor B12 or Trinfac.
4. Antibiotics for SID (small intestinal dysbiosis) - Blu is on metronidazole, which is often used to treat SID. It can have some nasty side effects, though, if used long term, so just watch for that. The preferred antibiotic for SID is Tylan (Tylosin). SID is often hard to eradicate completely in EPI dogs, and tylan is safer than metronidazole, so if he needs more antibiotics after this round of them, I would ask for tylan.

As for the other meds he is on, just let us know exactly what they are for and why they prescribed them, if you know. Just want to make sure he's not being treated for anything else at the same time. I'm not familiar with some of them, so hopefully Olesia will jump in soon and be able to help you out with suggestions on the other meds.

One last thing...if it looks like you won't be getting the Pancrezyme for a few more days, you might want to take a look at the "Emergency Enzymes" page under the Managing EPI tab. If you can get your hands on any of those options, it won't be perfect, but it will be better than nothing while you wait for the enzymes.

Good luck!

Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

Re: New Diagnosis - Please help!

Post by Rapids77 » 17 Jun 2020, 16:44

Oh my goodness Shirl - thank you for responding! I've never been on a dating website but I think I have had the same feeling today as I would on a site like that as I constantly check back to see if I have any responses to my post! I'm going to go through your post and answer based on your numbered response:

1) I am desperate to get any enzyme, yes! I found an emergency list on enzymediane (and am corresponding with her as well) re: getting started ASAP on any enzyme. I ordered the "Now Super Enzymes" from this site and also the "NOW Supplements, Pancreatin 10X 200 mg". Diane helped me figure out the proper dose of the Pancreatin 10X as she had recommended 4x and I couldn't find that anywhere (nor do I know what the difference is between 10x and 4x and google has failed me).

2) Vet #2 put Blu on RC Gastro before we got the EPI diagnosis (I literally got the call from Vet #1 with results while I was at Vet #2 picking up Blu after his two-day hospital stay). Vet #2 read the TLI results and said to stick with the RC Gastro food and all prescribed meds even with the EPI diagnosis. I don't think much thought was given to an alternative strategy after we got the EPI results. I have already ordered a bag of Sport Dog Food Elite -Herding and it should be here in about 2 days from Chewy. Do you think I can just fully transition right to that food? His diet has been ALL over the place for the last 3.5 weeks. Originally on Natural Balance with Ziwi air-dried lamb topper, then to me cooking boiled chicken, rice, pumpkin and chicken bone broth then straight to this RC Gastro since Sunday when he went to the hospital.

3) Blu received an injection of B12 at vet#2 on Sunday. But there was no mention of continued supplement B12. Thankfully you wonderful people on this forum and Diane make it very clear how important B12 is!! So I've ordered the Wonderlabs Pet Factor B12 and that will be here Friday as well. I see the dosing is 1 capsule if they're under 50lbs and 2 each day if they're over. Well, he's currently 48lbs and dropping but he SHOULD be closer to 70+lbs. I'm guessing that I should start with the full 2 capsules each day? How do you know if you need to ALSO get supplemental B12 shots in addition to the daily capsules?

4) I did also see that everyone recommends Tylan over Metronidazole. Is it worth it to call the vet and try to switch the prescription? He would have started the Metro on Sunday so he's only 3-4 days into it at this point? I don't think either vet #1 or #2 know a whole lot about EPI so I have no problem requesting different meds!

5) Other meds - all prescribed / just started on Sunday at Vet #2. Prior to taking him to the ER Vet he was on prednisone and doxycycline. It seems like there are WAAY too many drugs right now. He's on:
A) Maropitant: anti-nausea meds (he has NOT been throwing up but I guess Vet#2 wanted to make sure it stayed that way...or she was worried he would with all the other meds)
B) Pain meds (I actually stopped these as they made him a robot and he doesn't seem to be in pain)
C) Diphenoxylate: anti-diareha meds (seems silly now that we know why he has diarrhea and that it won't stop until he gets enzymes??
D) Ciprofloxacin: Antibiotic (I don't know why this one was prescribed...I will call and find out)
E) Metronidazole: antibiotic (prescribed before we knew he had EPI so not exactly sure if they thought he had SID prior to EPI or why exactly this was prescribed
F) Short-term probiotic (called Proviable) which will be out in a few days.
G) Omezprazole: Antacid
H) Prednisone: Originally for joint inflammation and because we thought he had low blood platelets which vet #2 said he does not have but he does have low blood volume.

Thank you again for your response and the time you've taken to send such great information, it is truly appreciated more than you know!

Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

Re: New Diagnosis - Please help!

Post by Rapids77 » 17 Jun 2020, 16:51

One last thing - Blu does have Anaplasmosis as well. Basically a tick disease similar (kind of) to Lyme's disease. Vet#1 has been treating for that and all the antibiotics (we've tried two different types trying to clear up diarrhea) clearly aren't helping since we're actually dealing with EPI. The tick disease doesn't present symptoms like EPI but I will need to make sure that he's getting treated properly for that - although all the antibiotics that he's had in his system now have probably taken care of / managed the tick disease.

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Shirl D.
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Posts: 86
Country: United States
State: New York

Re: New Diagnosis - Please help!

Post by Shirl D. » 17 Jun 2020, 18:21

I'm so glad you talked to Diane! She's great! I'm sure she's got you on the right track for emergency enzymes. And, for future reference, Diane's enzymes work just as well as the Pancrezyme you're getting, but they are a lot less expensive, so consider ordering from her in the future. No need to pay more for a fancy name!

The RC gastro food can be a life saver for dogs with gastrointestinal issues, so vets often prescribe them for EPI dogs, too. In theory, they should work, but for whatever reason, our dogs just don't seem to do well with them. Vets don't usually know this (because they've never lived with an EPI dog), so I'm not at all surprised that he recommended continuing with it even after the diagnosis. I'm sure he thought it would be good for him. I've heard several people say they've had really good results with the Sport Dog Elite; just be aware that what works for one EPI dog doesn't necessarily work for another. I just don't want to be totally surprised if it isn't the right food for him. We don't know until you try it, and I think that is a great first choice to try. We usually recommending just switching all at once when starting the treatment and new food for EPI. No need to continue to feed something that is probably not good for him.

B12...yes, I would start right off with 2 pills a day. You can't really get too much so it won't hurt while he's gaining a couple pounds to get him over the 50 pound mark. The blood test is the only way to know for sure what the B12 level is, but sometimes you can get a good read on it based on symptoms. I would say if the food aggression gets better and his EPI starts to stabilize, you will probably be good. However, it's always good just to keep it in mind as something to check if things aren't right.

As for the metro vs tylan, I would probably just stick with the metro right now, assuming it's a 10 or 14 day supply. I wouldn't give it longer than that. Once he stops the metro, if you see a difference in the next few days, you'll know you need to treat it again, and at that point I would say to go with tylan.

Definitely continue to give him any meds he's still on for the anaplasmosis (I see the pred listed but not the doxy). You don't want to mess with that.
A. Maropitant - If he's not nauseous, I would question whether he needs it or not like you are. I would think it wouldn't hurt, but is it helping? Unfortunately I don't know enough about it to offer a solid argument one way or the other.
B. Good you stopped the pain meds if they weren't helping anything.
C. Diphenoxylate - probably isn't doing anything, since you said he's still having diarrhea. I would probably hesitate to use it, but not being a vet or having a medical background, I don't really know what it's supposed to be doing. Is it treating what they thought was the problem or is it supposed to be masking the symptom?
D. Ciprofloxacin - Find out what it was prescribed for. We don't want to take away anything he needs. If it's for the diarrhea or SID, it's probably worthless.
E. Metro is frequently used for SID, and it was probably pretty evident to your vet that he had SID, whether he had EPI or not, so it's likely that's what it was prescribed for.
F. Proviable - probiotics can be helpful for EPI dogs, but again, each individual EPI dog responds differently to different probiotics. We actually usually suggest not giving probiotics when you are trying to get your dog stable, as it adds in one more variable to the mix. We like to keep it as simple as possible in the beginning...one food with enzymes, B12, and sometimes antibiotics. We start those up and wait 5 days or so to see what the results are. Based on the results, we may need to tweak things, possibly increase or decrease the enzymes or try a different food. If we add probiotics to this mix and things aren't improving, it just makes it harder to figure out which thing needs to change. Is it the food, the amount of enzymes, or the probiotic that is not working? So, I'm not sure if it will make a big difference whether you stop the Proviable now (since you don't have the food or enzymes yet) or keep it until they come, but either way, I would suggest not doing any more after it runs out.
G. Omeprazole - Many of our dogs have some reflux from the SID. If you think it is helping with his comfort level after he eats, by all means continue it.
H. Prednisone - Follow the doctor's instructions on this one. Stopping prednisone prematurely can be dangerous. You typically have to wean them off it.

Following up on my comment above about needing to tweak things...it helps if you keep a log. That way, you can look back and see what you have tried and what the results were, and sometimes you can find a pattern that can help figure things out. We have a template on the website that you're welcome to use. Here's a link: https://epi4dogs.com/epi-log/ I think Diane has one on her site, too, or you can always make your own. I always thought I would remember, but I never did! lol!

I know what you mean about waiting for a response on the forum! Your analogy to online dating cracked me up!

Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

Re: New Diagnosis - Please help!

Post by Rapids77 » 18 Jun 2020, 14:24

Good news! We received some enzymes today! Diane also sent a supply of hers expedited so we should be stocked up for a while. It was honestly the most exciting package I've gotten in the mail in ages (and I shop far too much).

Now, the question is how long should I expect before seeing any change in poop? Blue has had horrible diarrhea for the last 3 days again (I'd say around a running #2 on the poo scale) and he's starting to act pretty lethargic again. He had put on a few pounds at the ER (likely from fluids and not pooping much because of all pain meds and such they had him on) but now he's back down a few pounds to around 46lbs. It's just so heartbreaking to see. He did have his first meal at about 11:30 with the enzymes (they hadn't arrived for his first meal at 6:30AM and I think all of that meal came out instantly after he ate).

To answer your questions Shirl - the Metro is a 14 day script. I still haven't gotten an answer from the vet on WHY they want him taking Ciprofloxacin but would like to stop that ASAP if it's not for a specific reason as the fewer meds he has in his system just seems better to me.

One other question: Should I also be incorporating slippery elm into his meals? I see alot of talk about slippery elm but I'm not exactly sure when / if I should also add that?

The new food and Wonderlabs B12s will be here tomorrow and I'll start him on those ASAP as well. Thanks again for all of your help and hand holding - this is just SO scary!
Andrea

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Shirl D.
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Country: United States
State: New York

Re: New Diagnosis - Please help!

Post by Shirl D. » 18 Jun 2020, 14:56

Andrea, Yippee on the enzymes arriving! You should see some difference within a couple days, although it's difficult to really pin it down. It depends a lot on his "transit time", that is the time it takes for food to move through his system. The food he just ate with the enzymes should be digested and absorbed more thoroughly than the previous food, so when this food comes out, it should be firmer and a smaller amount. It probably won't be perfect, especially if the food isn't a good one for him, but it should be better. Transit times can run between 12 and 72 hours (if my memory serves me correctly).

The metro may really help with the SID, so I'd stick with the 14 days of that. I'm more concerned about side effects if dogs are on it longer than that. I agree with the cipro...it would be nice to know why he's on it.

As for the slippery elm, it can help, but just in the interest of limiting the variables, I would suggest holding off right now. Let's see what happens with 5 days or so of the enzymes, new food, and B12 capsules, since they'll be here soon, too.

We're happy to help! We've all been there and we remember what it was like. Hang in there. Try to be patient for the next few days, and keep us posted! Keep asking any questions you have also.

Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

Re: New Diagnosis - Please help!

Post by Rapids77 » 18 Jun 2020, 15:28

Awesome advice on the SE! And since you gave me the green light here are few more questions :lol:

The exciting news is that he has NOT pooped yet since his meal at 11:30 which is unheard of for him as of late as its typically within 20 minutes we're seeing the food come shooting out (sorry). The not so exciting news is that he's really down / sad and kind of lethargic. He was not all too pleased about the enzymes in his food but was so hungry he begrudgingly ate almost his whole bowl. I've seen that adding some green tripe works great for lots of dogs (and he's used to raw meat that we used to supplement with his kibble and he loved it) so perhaps I should get some of that as a back-up in the event he starts refusing the kibble with the enzymes? Or would you suggest just doing parmesan cheese or bone brother over it instead to start if he refuses? I added a little parmesan today and he loved that, but essentially just licked it off and then stared at the food like....oh, now I'm back to this junk huh...

Also - is there anything wrong with some adding bone broth to his water to get him to drink more? His water consumption seems to be down quite a bit today and I want to make sure he's staying hydrated with all the diarrhea he's having? If that's not good, any other suggestions to get them drink more water? Maybe that'll come naturally with the enzymes as Ive seen on here that drinking more (and subsequently accidents in the house) are pretty common at first. Thank you!!

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Shirl D.
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Country: United States
State: New York

Re: New Diagnosis - Please help!

Post by Shirl D. » 18 Jun 2020, 16:19

I'm sorry to hear that he seems to be not feeling well. It sounds like he's had a rough couple days, so that may be catching up with him. Hopefully he'll start feeling better soon. I don't know if you've seen any of the before/after photos on our site, but one of the things I notice a lot is a huge difference in the look in their eyes and their body language. They are obviously not well in the before photos, but have so much life and happiness in their eyes in the after photos.

The enzymes definitely have a smell and it does turn off some dogs. My Pixie sometimes gets into picky stages, where she doesn't want to eat well for a week or so, but then she'll start eating fine again. She does the same thing with parmesan cheese...licks it off the top and she's done! You can try pretty much anything, including green tripe, just make sure you're not adding enough to throw off the ratio of enzyme to food. Someone on Facebook recently mentioned that her dog will refuse to eat unless they add liverwurst to it! You could also try using broth (lukewarm) instead of water to mix the enzymes in. Check out the Camouflaging the Enzymes page under the Managing EPI tab for more tips. With Pixie, feeding her in a wide, shallow bowl made a huge difference. I don't see any reason why you couldn't add some bone broth to his water, as long as you know it doesn't have a high sodium content. Another thing might be to give him some ice cubes. My dogs think they are a wonderful treat, and it gets extra water into them.

Hang in there!

Rapids77
Member
Posts: 18
Country: United States
State: Wisconsin
Pet name: Blu
My name: Andrea

Re: New Diagnosis - Please help!

Post by Rapids77 » 18 Jun 2020, 23:32

I’m so overwhelmed and confused and it just hurts to watch this guy suffer. I knew getting the enzymes wasn’t going to be an instant fix but he’s gone sooo downhill since starting them late this morning.

Blu’s now stumbling all over and dragging his feet as he walks and running into things. He’s drinking a lot of water now and the poop isn’t nearly as frequent so that’s good but my goodness I didn’t expect him to get worse today...was praying for even a slight improvement. I’m thinking we’ll be going back to vet ER in the morning where I know they’re just going to pump him full of all sorts of meds that likely won’t help but maybe just an IV with lots of fluids will at least help him a little. Ug, just so darn hard to watch and is so confusing.

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