C10020168 / invoice 10000

Reason: recheck IMPA. Intern: Rylan McCracken. Problem List: 1) Non-associative non-erosive immune-mediated polyarthritis (diagnosed on 24/09/2025). Relapse (documented by clinical signs and elevated CRP, 19/01/2026)> marked neutrophilic inflammation with 90% non-degenerate in L&R carpi, L&R tarsi, and R stifle (all joints sampled). > bilateral carpal radiographs showed no evidence of erosive lesions; only soft tissue swelling.> urine C&S negative; TXR wnl; abdominal ultrasound unremarkable other than mild prominent jejunal and medial iliac lymphadenopathy (not sampled).> no recent vaccinations or medication. Medication trends > commenced prednisolone 12.5mg PO BID on 25/09/2025.> introduce 50mg cyclosporin PO BID and reduced prednisolone to 12.5mg PO in AM, 6.25mg in PM on 16/10/2025 due to ravenous appetite. > 23/10/2025 prednisolone reduced to 12.5mg PO in AM, 50mg cyclosporin PO BID>13/11/2025 Prednislone reduced to 6.25mg PO in AM, 50mg cyclosporin PO BID > 04/12/2025: prednisolone reduced to 6.25mg EOD, 50mg cyclosporin PO BID > 31/12/2025: stopped prednisolone, 50mg cyclosporin PO BID > 19/01/2025: relapse of lameness, elevated CRP. Restarted prednisolone 12.5mg PO SID, continued cyclosporin 50mg PO BID > 19/02/2025: no lameness, CRP <10. Continued prednisolone 12.5mg PO SID. Stopped cyclosporing, commenced leflunomide 30mg PO SID (elected to change second line drugs due to lack of maintained remission on cyclosporin without prednisolone previously) 2) Mild popliteal lymphadenopathy.> cytology (24/09/2025): reactive lymphoid hyperplasia. 3) Intermittent hyperlipidaemia > commenced post steroid therapy and subsequently resolved after dose reduction. 4). Hyperabluminaemia and hypercalcaemia - likely secondary to hyperlipidaemia 5) Mobile, non painful 'nodule' over the craniolateral aspect of the tendond/ligaments of the right hock. History: Riolu has been well since last visit. No ongoing lameness/stiff gain, ambulating and playing normal. Normal appetite, no increase in thirst/urination. No vomiting or diarrhoea. No coughing/wheezing/sneezing. Panting in the evening, but no respiratory signs and normal respiratory rate/effort when sleeping. Diet: Prime 100 kangaroo & pumpkin roll and air dried. Current medications: Prednisolone 12.5mg PO SID, leflunomide 30mg PO SID Physical examination: BAR. Sweet boy. HR: xxxx bpm RR: xxxx  MM: pink/moist  CRT <2s  Temp: xxxOral: minimal dental disease, no pain on opening mouth, no visible lesions, minimal halitosis Ears: clear, no discharge, no erythema Eyes: no discharge no conjunctival/scleral hyperaemia, no pain on retropulsionNasal: no discharge, patent airflow, no depigmentation, no pain on palpation of sinuses, no evidence of deformityCVS: no murmur, normal rhythm, strong synchronous pulsesResp: eupnoic, panting, normal bronchovesicular sounds all quadrantsAbdomen: no pain on deep palpation, no palpable fluid wave, no masses palpableGenitourinary: clear, no discharge Rectal: soft brown faeces, NSFMSK: No carpal, tarsal or stifle effusion appreciated. Good ROM. No lameness or stilted gait. No pain on palpation or manipulation of carpi, tarsi, elbows or stifles. Mobile, thickened nodule type structure on the cranial ligaments of the left hock (non painful - assessed by JK)Neuro: appropriate mentation, CNs WNL, no appreciable spinal pain. Peripheral LNs: submandibular LNs are bilobed, popliteal LNs are prominent but do not palpate enlarged, superficial cervical LNs are palpably normal Integument: clean coat, no alopecia or lesions, shaved hair has regrown well. No perinal erythema BCS:   xx/9. MCS xxx/3Weight:  xxxxLaboratory: CBC - CHEM - CRP Problem List: Assessment: Riolu has been diagnosed with non-associative non-erosive immune-mediated polyarthritis. He responded favourably to immunosuppressive therapy but relapsed after discontinuation of prednisolone despite full dose cyclosporin. He has subsequently gone back into clinical remission after restarting prednisolone at ~1mg/kg/day. Given this, Riolu is not likely to respond positively to cyclosporin long term an alternative second line immunosuppressive drug is advised. While we could consider cyclosporin trough testing in case Riolu is having inadequate absorption, there is poor correlation between pharmacokinetic and pharmacodynamic monitoring (ie between cyclosporin blood levels and IL2 levels) which raises concerns in interpretation of these results. Riolu may need lifelong immunomodulatory therapy. While the prognosis for idiopathic IMPA is good, with 85 - 95% positive response, there is a high rate of relapse, with ~40-60% of dogs relapsing within 24 months of commencing treatment. It would be recommended that potential triggers of immune-mediated disease should be avoided in Riolu; this includes non-core vaccinations and certain antimicrobials (such as TMS, cephalosporins and penicillins). The origin of nodule over the craniolateral aspect of the tendond/ligaments of the right hock is unknown. This may reflect a benign fibrotic focus, granuloma, cyst, or less likely neoplasia; it does not palpate as an osteophyte/enthesophytes as it is mobile. If this is persistently present, a FNA and ideally radiographs should be performed. This was assessed by one of our surgeons today. Plan: Continue prednisolone 12.5mg PO SID. Stop cyclosporin. Continue leflunomide 30mg (20mg & 10mg tablets) PO SID Continue q2-3 weekly bloods are advised for the first two months on treatment of leflunomide, and then monthly for the following three months. This may be pushed to q2 monthly if going well. If going well (no adverse effects, no lameness, normal CRP +/- lack of inflammation on arthrocentesis), consider tapering prednisolone by 25% after ~8 weeks on leflunomide (mid April 2026). Prednisolone may be tapered at 25% q8 weeks, followed by tapering of lefulonomide q8 weeks. Client communication:    Vital Signs