Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - 8 yr old English Springer Spaniel

At this point I could do with some advice about Pinny who was diagnosed with AIHA. The first treatment recieved was prednisolone 2.5 tabs a day (5mg tabs). Her blood count went up gradually from about about 29, cannot remember exactly, to about 43. At a check we mentioned she was very hungry, vet suggested weetabix as a filler, this gave her diarrea, which we treated with some large tablets for 24 hours, after about 3 days it cleared up. The next visit the vet dropped the tabs to 2 a day, and from then on, about the last 2 months, her blood count has been dropping. The vet put the tabs back up to 2.5 a day and also added 1 and 1 fifth 25mg tabs of azathioprine. Ater a week we had a blood test which was 34, still dropping. Today the vet said she wants to do x rays of the chest and stomache, £255 worth. I have been reading your messages and researching other sites and I am puzzled , I read that azathioprine takes up to six weeks to work and changes in tablet amounts should be done one at a time so as to know which change worked I presume, sorry about the lengh of this. I have not read of any cases where the preds started working and then stopped, perhaps someone has had a similar experience or knows if x rays are likely to help. Vet seems very vague, did not even give me one of the blood test results because it was done in house and would be different to the lab, cannot see the point of paying for that one, money tight at the moment and would rather spend on treatment that might be usefull. Just thought I would run this past you before having x rays, or changing vet, thanks for reading all this.

shaz England

Shaz...you didn't include your e-mail address so I will send this to you over this forum. This was reviewed and edited by Jean Dodds, D.M.V. whos probably knows more about this disease in the USA than anyone. Hope this helps..

Protocol for treating IMHA:
(Immune-Mediated Hemolytic Anemia)
Reviewed and Edited by: Jean Dodds, D.M.V. 2007

History:

1. Any history exposure to ticks, any travel to tick infested areas? Other infectious diseases such as leptospirosis, bacterial or fungal or parasitic diseases.
Test to rule out Babesia, Ehrlichia, Bartonella, & Rocky Mtn. Spotted Fever, Lyme, as causes.

2. On any current meds that could cause anemia, thrombocytopenia?
For example, Sulfatrimethoprim. Estrogens, non steroidal anti-inflammatory drugs?

3 Has there been any exposure to rat poison? Zinc exposure (in the form of coins; seen on X-ray)

4. Were there any recent vaccines (w/in last 3- 45 days?

3. Any concurrent health problems?
Neoplasia : Hemagiosarcoma, Sertoli cell tumor, lymphoma. Other conditions: Hypothyroidism, especially autoimmune thyroiditis; Cushing’s disease; Addison’s disease; diabetes; any other recent illness or surgery or stress event including sudden change in temperature?

Diagnostics: Minimum data base

1. CBC including platelet count and platelet size (immune-mediated platelets usually have predominantly small platelets).
2. Check Purple Top Tube for auto agglutination, check slide for
auto agglutination, look for spherocytes, or stomatocytes on the peripheral blood smear
3. Manual differential, cell morphology (regenerative anemia? (at least 30%
of IMHA cases are not regenerative)
4. Spherocytes (near the feather edge don't count)
5. Platelet estimate consistent with low count or due to clumping?
6. Chemistry panel ( Low albumin may indicate hemorrhage)
7. Chest rads & abdominal rads to rule out cancer, pneumonia.
8. Abdominal rads to r/o zinc toxicity (metal coins), cancer, pyometra,etc.
9. Abdominal Ultra Sound to check for Neoplasia(i.e. dog >7yrs)
10. Babesia titer or other infectious diseases if greyhound or if there’s travel history, Ehrlichia, RMSF, Lyme leptospirosis, titer if also thrombocytopenic.
11. UA - look for hemoglobinuria
12. Coagulation panel if evidence of exposure to rodentacides. Or suspected Neoplasia.
13. As the underlying cause can be autoimmune thyroiditis, and thyroxin is needed for normal hematopoiesis, check full thyroid antibody profile.

Treatment: (Discounting any current meds!)

1. Prednisone 2mg/kg PO BID divided; start at same time as Dex SP is
given
2. +/- Azathioprine (Imuran) 2mg/kg PO SID if dog is not responding to the prednisolone.
3. +/- Cyclosporine (Atopica) starting at 10mg/kg SID for the first week, then 5mg/kg thereafter, if patient is refractory to the above drugs.
4. Pepsid–AC to prevent gastric ulcers from the prednisolone.
5. Doxycycline 5 mg/lb bid just in case it is Ehrlichia
*Do not use Cytoxin, Oxyglobin - studies show a decreased survival rate with these drugs.
6. Thyroxine (0.1 mg / 12-15 lbs. of optimum weight BID), to stimulate hematopoiesis, or if patient is hypothyroid

Transfusions:

a. Better to transfuse sooner than later.
b. Transfuse if PCV<15% or ( >12% if reduction in PCV is not peracute).
c. Use Packed Red Blood Cells (best) or Fresh Whole Blood.
d. True universal donor (DEA 4) is best as you usually can't type or cross-match due to auto agglutination.

Monitoring:

1. CBC q12hrs, initially, then every few days depending upon the patient affect.
2. Monitor electrolytes q24hrs if on IV fluids
3. Monitor the slide for agglutination q12 - 24hrs
4. Blood smear every few days to look for regeneration, platelets (platelet half-life is 3-5 days; platelet count may not go up because the new platelets go first into the inter endothelial cell spaces to “plug the holes” as seen by fading of bruises or pinpoint hemorrhages and no more new ones; then the next batch circulates and raises the blood count.)

Sending home:

1. Prednisone 2mg/kg PO divided BID for at least two weeks, taper very slowly every 10-14 days for another month until platelet count is above 100,000 or PCV is above 21 and stable. Then decrease dose, whenever the blood tests remain stable for two weeks. Eventually the steroids should be given every other day for maintenance.
2. Dogs usually require low dose prednisone every other day for a year or more.
3. Azathioprine 2mg/kg PO SID if needed, then reduce to 1 mg/kg SID, then to 1mg/kg every other day or three times per week.
4. Continue cyclosporine, if needed originally, at 2.5mg/kg SID
5. Continue thyroxin, if needed originally, at 0.1 mg /12-15 lbs. of optimum weight BID, given at least an hour before a meal to ensure absorption.
6. Pepsid-AC PO and Sulcralfate while on high dose prednisone.
7. Recheck CBC weekly to start; CBC at 1 week, 3 weeks, and then q2
- 3 months while on Azathioprine

8. High protein (35%), low fat diet, no corn, wheat or soy. Split normal amount of food into four servings.
9. Consider Jean Dodd’s “Liver Cleansing Diet” if liver functions are high.
10. Milk Thistle and/or SAM-e for liver health.
11. Pet-Tinic added to food (for iron, B12, folic acid, copper, necessary to form new RBCs).
12. Have plenty of fresh water available for the dog at all times.

RonB San Mateo

Shaz,
Hi, I also have an English Springer who has had the disease since 2005, and is doing quite well. You didn't mention about how much Pinny weighs, or how long he has had AIHA, but the pred dosage seems low to me. Spencer started out at 40mg a day at the onsite of this (along with Pepsid). Neoral and Azio were added at a relapse. see the above protocal for dosage per weight.
Xrays are used to rule out any other types of problems. If you are uncertain of your vets familiarity of the disease, an internal medicine specialist should be consulted, or another vet familiar with the disease.
My thoughts are with you since I have a big soft spot for the Springers.
Kim and Spencer

Kim NY

Ous springer,Cody, is a survivor. His prednisone rate to start was 1 mg per pound per day ( He's a big boy weighing about 57 lbs and was on 60mg of pred.... 30mg am, 30 mg pm) I think this is standard procedure.......the weaning process is a very slow one, to hopefully avoid any relapses.

Betty Dallas

Shaz, sorry to hear about Pinny. We have a Collie X, she came down with AIHA last Sept/Oct and was put on Pred 2x25mg, morning and evening, Azi and Antepsin was also given to protect the lining of the stomache.
She was taken off Azi 3 weeks ago because it was supressing the immune system too much, she is now on Zantec, the Pred has been dropped to 1 in the am and 1/2 in the evening. Zantec and Antepsin is being given in liquid form now. It is a long process Shaz. Trixie's PCV is now 31 and her WBC are normal again. The pred won't be reduced until perhaps 2 more weeks, all depending on her blood count.
There is lots of imformation on this site Shaz and you will get lots of support. When Trixie goes for her blood tests at our local vets, they check her PCV, the rest of the tests are sent to Bristol Lab' where they have more specialized, up to date equipment and the results are more accurate.
Tricia

Tricia UK

Penny(pinny was a typing error sorry) weighs 37 pound, she is a small springer, so she should be on 37mg of pred, she was on 25 at first (around sept 07) and her pcv rose slowly from 29 to about 43 between then and about november, her preds were put down to 20 mg 2x5mg tabs a day, and her pcv has been dropping slowly untill now, it is 34,. I did ask the vet if this was the reason, but she said preds were reduced before the pcv dropped and she did not want to increase the dose, after a few weeks and finding no blood in a faeces test, she put the preds back up to 25mg and added the azathioprine. Should the pcvs have been stable for a while before the preds were reduced in the first place? and I am wondering why she put them back up when she had said she did not want to earlier. Penny did not have a vacination prior to this we were late with her annual one when all this started so luckily it never got done. It all started when she ate a lot of leaves off a bush that we had been trimming from over neighbours fence, she started vomiting the leaves back up, she then got the runs, I took her to the vets thinking the leaves had poisened her but he said not, he noticed her eyes were a bit red and gave her some drops, these did not work so they gave her antibiotic drops. After a while, not sure how long, maybe a month, she started to urinate blood, really thick and dark (she had done this earlier in the year, they treated her for an infection and it went), The vet said she had stones and put her on a special food to dissolve the stones, we fed her nothing else then one day she seemed really quiet, her tail was not wagging and she kept sitting down, not springer behaviour, took her to the vets and they did xray and no stones were there, this is when they came up with IMHA, she said it was regerative and there were billirubin showing, the coombs test was negative, but said this could happen and she was sure it was IMHA. Will agree to xrays but if they show up nothing I do not know how they will get her pcv to go up. Decided to warn the kids the worst may happen one day, dont know how low PCV can go, or if we would have to put her to sleep before it got that bad. thanks for replying, will keep you imformed(and keep it shorter). Good luck with your pets

shaz England

Shaz -- it sounds like you have a vet who isn't experienced at handling AIHA/IMHA. It sounds like the prednisone reduction occurred too quickly, and some vets/patients want to reduce quickly, because the side effects from the prednisone can be hard on the dog. It sounds like Penny was responding to the prednisone, so if the vet keeps her on prednisone until good regeneration and reduces gradually, she might do well.

But the prednisone reduction must be gradual. It also sounds like some folks here think the prednisone dosage wasn't right. I'll see if I can find Joanne's guidance on the prednisone and post it here for you.

Brenda VA

Dexter our 10 year old Springer Spaniel has been diagnosed with AIHA this weekend. I know nothing about this disease and the long term effects. We are struggling to get his blood count up over 20 at moment, however after 48 hours of not eating anything that changed this afternoon and hasn't stopped since according to the vets.

How long do the drugs take to kick in I can assume that something must be happening to make him now want to eat, is this a good sign or a red herring.Whilst his blood is so low, he does still manages to walk outside and do the necessary....He also seems bright in himself.

Anything would help, how long etc........

Bev Essex

This thread was discussed between 01/02/2008 and 25/02/2008

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