Photos courtesy of Jerry and Lois Photography
By Ranny GreenShe began thrashing around in her crate about 4 a.m. with a much-worsened condition than when I brought her home from The Animal Emergency Clinic in Tacoma several hours earlier. Her eyes were glassy, her four limbs were splayed. She had that rigor-mortis look and I had that feeling she was on death’s doorstep.
Maggie, our beloved little, 14-months-old Pembroke Welsh Corgi, had been battling Giardia all summer under the care of our primary veterinarians Drs. David Farris and Elisabeth Teberg, of Cascade Veterinary Hospital in Federal Way, before being referred in October to Dr. Brad Green, an internal medicine veterinarian at the Puget Sound Veterinary Referral Center, allied with The Animal Emergency Clinic.
Giardia is a single-celled parasite that lives in a dog’s intestine and can be very difficult to rid. It enters the organ after the animal swallows water or other substances that have been contaminated with feces. Often the symptoms aren’t manifested immediately but eventually the parasite(s) begin damaging the intestinal lining, affecting digestion and resulting in a mix of other symptoms. For Maggie, those included loss of appetite and weight loss, lethargy, weakness, diarrhea and bloody stools, dehydration and a fever (105.1 degrees in Maggie’s case).
We adopted her in late May and it wasn’t long before she began exhibiting some of these signs. In late June, she was rushed to The Animal Emergency Clinic with several of the symptoms and diagnosed with Giardia based on fecal samples presented. I brought her home a few hours later with metronidazole and panacur, the drugs of choice for combating the disorder, and she was placed on a bland diet of cooked turkey and chicken, along with rice. And I was advised to schedule her for a recheck appointment at Cascade Veterinary Hospital within three days.
Throughout the summer, Maggie’s symptoms never disappeared, although they abated at times, while remaining on the two prescribed drugs, leaving my wife Mary and I feeling helpless with no relief in sight. One day she felt like eating, the next day she refused. One day she was energetic, the next disinterested and weak. During this span she tested positive for Giardia twice.In late September, Maggie was again returned to The Animal Emergency Clinic with similar signs and a temperature of 104.6 degrees. A radiograph revealed a large spleen but the veterinarian saw no concern of an obstruction, although Maggie was sensitive when touched in the abdomen. A blood panel didn’t reflect anything startling, either. She was given subcutaneous fluids, again placed on a bland diet and sent home.
On a referral from Teberg, Maggie was brought to Green in late September for an exam and consultation. A fecal parasite exam identified only roundworms and a Giardia ELISA reading was negative. Medications to treat roundworms were prescribed.
Because her symptoms persisted, another stool sample was brought to Green Oct. 16, this time revealing a reverse of the Sept. 26 findings – negative parasite and positive Giardia ELISA readings.
Green’s report back to Farris and Teberg read, “It is conceivable that Giardia has been the cause of each of her episodes of illness. It is not surprising that on occasion she has tested negative for Giardia, since testing for this condition lacks sensitivity. Furthermore, it is not uncommon for Giardia to be resistant to both metronidazole and panacur. On the other hand, some dogs may be carriers of Giardia and remain asymptomatic. With this in mind, it is also possible that Giardia is not the cause of Maggie symptoms. Nonetheless, more aggressive treatment for Giardia is indicated. Ronidazole has been prescribed.”Because it was not available commercially, we purchased ronidazole from an Arizona compounding pharmacy and began treatment with 500 mg doses twice daily six days later. Everything went well for six days but on the seventh and final day the drug was to be administered, Maggie rejected her evening meal and her balance suddenly became unsteady. At one point, she slid down our carpeted stairs (a first) to a crash landing, prompting me to alert the emergency hospital that I would immediately be en route with her and asking them to inform Green of the situation.
Maggie remained hospitalized five days for ronidazole toxicosis and has been healthy since. Follow-up fecal samples are recommended monthly for three months. Her first two on Nov. 12 and Dec. 13 were negative on both counts; her activity level is just what you would expect for a young corgi – vibrant and sometimes supercharged.
The overriding lesson here is that veterinary medicine, like its human counterpart, is imperfect. Drugs of choice are ineffective in some cases and build up a residual toxic reaction in some patients that render them very sick or occasionally prove fatal.
“I prescribe dozens of medications every day and rarely see problems,” explains Green. “Medications, in general, are very safe. But having said that, unusual reactions are common enough that I am not surprised when they happen. It is a reality of medicine. Nearly every drug has at least one known side-effect. Nearly all of these will resolve when it is withdrawn if the administered dose was appropriate.
“Maggie was an example of a patient who needed intensive supportive care in the form of IV fluids and sedation.” During her hospitalization, she was also administered a drug for motion sickness.
The frustration of the owners after their pet suffers a drug reaction varies. Green noted most are frustrated, yet understanding. “Until, I tell them, most don’t know their pet’s new symptom is because of the drug. And most commonly, I am relieved to blame a new symptom on a medication because this will likely resolve once it is stopped. This is usually a pretty easy fix; definitely easier that telling an owner that their pet has another malady.”Highly troubled owners, Green says, need to be reminded that their pet was not well in the first place, which is the reason why a particular medication was prescribed. “After the initial frustration,” he adds, “people realize medications inherently have the possibility of causing side-effects.”
Dr. Katrina Mealey, a Washington State University College of Veterinary Medicine veterinary clinical pharmacologist, has not prescribed ronidazole for any patients and adds that it has not been tested in dogs nor is it FDA approved for dogs, hence no specific safety studies have been reported. One peer-reviewed article on its use in dogs was published last June and describes effective treatment without side effects for only six animals.
Mealey, who talks with several owners and/or veterinarians each week about adverse drug reactions, says cancer is the disease most commonly associated with the problem.
“I often receive questions from owners that go something like this: ‘Is drug X safe for my dog?’ My response is that no drug is 100 per cent safe for 100 per cent of the dogs. Period.”
For some drugs, she emphasizes, owners are urged to carefully monitor for early signs of toxicity and if they notice any unusual signs in their dog’s behavior, they are instructed to discontinue the medication immediately, hopefully avoiding severe drug toxicity.
When several prescription drugs of choice are available for a particular ailment like Giardia, Mealey’s first choice is one that is FDA approved for treating the condition. If that is not available, she goes for one that is FDA approved to treat a different condition in dogs. A third option would be a FDA approved human drug or FDA approved drug for a different species provided there is literature supporting its safety and efficacy for the condition.
The last option, she continues, is a compounded drug. If that is the choice, the compounding pharmacy is supposed to use an FDA approved version of the drug to make the compounded product. “Instead, and in some cases to save money, the compounding pharmacy will use what is called a ‘bulk’ drug,” emphasizes Mealey. ”Bulk drugs are not inspected by the FDA and the consumer has no protection from potential contaminants. This should be used only as a last resort with the owner’s informed consent.”
Teberg added, “Some drug reactions are predictable based on the drug used and some reactions are totally out of a control with an animal’s hypersensitivity to the medication. Veterinary medicine is not an exact science and many drug dosages are extrapolated from human medication dosages.”
She tries to discuss possible side effects of every medication that is sent home for a patient. “I make a decision to use a certain medication based on established drug protocols and my personal experience with the drug and how animals usually respond. If there is a drug I am unfamiliar with I will always discuss its usage with a specialist prior to using it or refer the client to the specialist.
“If I feel the animal is not responding to treatment or the case is challenging, the owners is always given the option to see a specialist. That recommendation is based on what is best for the animal’s health, but I also know that the owner is probably frustrated with the outcome and may seek other options. Some, however, choose not to take the recommendation and opt for continued treatment at this hospital.”
My takeaway lessons from Maggie’s exasperating melodrama: Be proactive, don’t hesitate to ask questions and be highly vigilant for the slightest changes in your dog’s body language and behavior 24/7. You are its No. 1 medical advocate and provider every step of the way.
Dogs don’t choose to become ill on our terms or at our convenience. In fact, the bulk of Maggie’s incidents occurred at night or on the weekend when our primary veterinary hospital was closed, hence immediate action for complete care was mandated.
Seeing her running, jumping and howling (a wolf-like woof) again is soothing and soulful, particularly after having to say goodbye recently to two other ailing, cherished family dogs. Maggie hasn’t just changed our lives, she has re-enforced our perspectives on the fragility of life with her will to live.