Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - A new case - Boomer

My dog is a 7 year old labradoodle. Middle last week, Boomer started to show a loss of appetite and over a couple of days was increasingly lethargic. On Friday morining, after about two days of this, we took him to an emergency clinic where he was diagnosed with IMHA. Upon arrival his PVC was 20%. Within a few hours it was 12% and he was given a transfusion. He was put on pregnisone and azathioprine and a very low dose of asprin (1/12 a baby asprin). After the transfusion, he had his PVC tested 3 times a day and it bounced between 18-22%. They let Boomer come home mid-day Sunday. He was tested yesterday morning and still at 18%; today we noticed he was a bit more lethargic and took him back in. His PVC was 16%. The emergency clinic then recommended the following: > Gamma glublin transfusion > Add Leflunomide to his drugs I have read more than I ever wanted to know about IMHA, emailed Dr. Jean Doods, and talked to Callie, a wonderful lady in Florida who is sharing what she experienced on other boards. I hadn't heard of either of these and the emergency clinic wouldn't let me talk to their internal specialists because of some silliness about Boomer still being an ER case. In the end, I said no to both of these and asked that instead cyclosporine be given and that they watch him over night to see how he does with his PVC. Due to Callie's advice, I had also added Pepcid AC, ProBiotics and milk thisle to the list when Boomer came home on Sunday. Our family is very sad - Boomer has been an amazing dog and as you all know, this nasty disease just hits you out of no where. I've read enough to have some idea what we're in for. We're expecting to hear PVC results in the next couple of hours - I'm hoping that it doesn't drop again but I'm expecting that and he'll need another transfusion in the next couple of days. Interestingly, I'm talking to a vet with significant experience with IMHA who told me she's practiced in California (So Cal near the ocean), Denver, and now Idaho. Her success rate was 75%, 25%, and now 50% and she's convinced that altitude plays a role. I haven't read that anywhere yet but she's been using the same protocol to treat IMHA for 10 years and all that's changed significantly is her location. I'm interested in what else we should be thinking about as we begin to walk this very hard road with Boomer. Thanks - Cal

Cal Idaho

I just read another thread and saw a couple of things I have specific questions on: > What is carafate - this hasn't been discussed by the vet. > I saw talk about some of the meds (cyclo) needing to be on an empty stomach. Again, nothing from the vet on this either. Which meds need to be given on an empty stomach or with food? How the heck do you give a pill to a dog without hiding it in some food? Throwing it down the back of his throat and holding his mouth shut doesn't sound like fun for him. I'm hoping there's an easier way. Thanks - Cal

Cal Idaho

Hello Cal, I am so sorry for what you and Boomer have to go through. It sounds like you have gotten some very good advice from Callie! Getting Dr. Dodds on board might just be the thing that will turn Boomer around. I think she will advise to treat with cyclosporin and whole blood instead of Leflunomide and Gamma Globulin. Carafate or sucralfate are a very important drug to give when dogs are on high prednisone doses. They coat the inside of the stomach and protect it. They can also help if there is already an ulcer. But it would be good if it never came to that. Please ask the vet for a prescription of Sucralfate or Carafate, insist on it! It would have to be given on an empty stomach. Cyclosporin is also given on an empty stomach. it is ok to give it wrapped in a bit of food. These dogs have to take LOTS of pills and you don't want them to start hating to take them. This little bit of food or pill pockets won't hurt. Prednisone and Azathiopene is given with food. Ask if the vet could get Boomers thyroid tested. Most likely it will be low and a supplement would be a good addition. Dr. Dodds advised to put my dog on thyroid meds. I hesitated and wanted to check it first, but as usual Dr. Dodds was right, the levels were low. Even if they are borderline a supplement will not hurt. I have never heard that altitude plays a role in this disease. I would guess that the change in success is coincidence. I think that humans that live in higher altitude have "thicker" blood, so who knows there might be a connection (clumping of the blood?) Maybe Patrice has an explanation? Good for you for reading and learning as much as you can! The more you know the better prepared you are for this fight. If you have not already found the Meisha's Hope site, please go there to learn lots and read the success stories: http://www.cloudnet.com/~jdickson/index.html they will give you lots of hope! Best wishes, Brigitte & the poodle boys

Brigitte BC

"In people acclimated to high altitudes, the concentration of 2,3-Bisphosphoglycerate (2,3-BPG) in the blood is increased, which allows these individuals to deliver a larger amount of oxygen to tissues under conditions of lower oxygen tension. This phenomenon, where molecule Y affects the binding of molecule X to a transport molecule Z, is called a heterotropic allosteric effect." What this says is that there is adaptation to altitude by the body. It's no mistake that this happens. If the body wants more oxygen to the cells, it will accomplish it, but over time (acclimates). So, put a dog or human at a high altitude and take away half or more of their hemoglobin in a few days. The body is crying out for more O2 but it can't adapt that fast. We often see here on this forum that some dogs can live quite well for long periods of time with relatively low PCV packed cell volumes (say 20%) while other dogs are extremely sensitive to only moderately low PCV (say mid 20's) in the short term and show severe symptoms of anemia. So I guess if one is going to have autoimmune hemolytic anemia, it would be better to be at a lower altitude. Dr. Dodds gave me a great idea from her book about how to give Cassie her thyroid pill. We buy those little marshmallows and put in inside. But after awhile, dogs get pretty clever about avoiding pills. Rotate stuff. Anything that is of high value to the dog, but not everyday. I remember at one point resorting to buying cans of real cheese spray. I used bits of cream cheese, bits of dog cookie with natural peanut butter. My vet said smelly fish like sardines. Some pills are very bitter and if you touch them and then the food, you can rub the bitter onto the outside of the food. So avoid touching the pills directly. Try to avoid battles over giving pills. I have been there, it's not fun. I remember one day using canned salmon and then trying to find all 9 pink prednisone pills on the kitchen carpet (confetti pink colored) among dozens of little pieces of pink salmon. One method that is pretty successful is to make three high value small treats (one has pills in it) and offer them on the flat of your hand. Give one at a time quickly and the dog will be eager to get to that last one. Be sure that Boomer has had a good physical exam, especially of the abdomen. You may want to request a rule out x-ray as well. Dogs, esp males, of that age have more of a tendency to certain tumors. You want to make sure that is not a factor. You want to make sure that they have tested for tick diseases. There are several that will cause this kind of sudden hemolytic anemia. Most of these are treated with high prolonged doses of doxycycline. Keep copies of all records like the CBC and chem screens. They are yours. We can help you read them from test to test. Here is something you can read about Gamma Globulin: Treatment of nonregenerative anemia with human gamma-globulin in dogs. http://www.ncbi.nlm.nih.gov/pubmed/7540607 my best patrice

Patrice NYS

Cal, So sorry to hear you are going through this. In addition to all the great advice given above -- perhaps you can call the Internal Medicine practice at the hospital and make an appointment for Boomer at this point. I can understand how the Critical Care vets want to keep their patients on their service; however, chances are the IM vets have much more experience dealing with this disease. I would think that routinely the case would be referred to them, but it doesn't sound like that is happening at your hospital. Perhaps you can get an appointment today or tomorrow to get Boomer evaluated. I would encourage you to do what you can to get IM on board sooner rather than later. Good luck! Hang in there! Sharon

Sharon PA

Thanks all - Boomer's PVC at 1 AM today was 15 but the vet I talked with said he looked good - "has a spring in his step" as they were taking him out to go to the bathroom and based on that, she didn't want to proceed with a transfusion last night. I guess we'll be closely monitoring him over the next few days and hope either his PVC starts to go up or we'll be doing another transfusion. Boomer was put through a battery of tests when he arrived at the hospital last Friday - probably around $1500 including x-rays, ultrasounds, complete blood panel, and tick panels (even though they almost never see ticks here, they wanted to rule that out). The chief internist is who originally called us on Friday to say nearly everything that causes his sypmtoms (e.g. cancer) had been eliminated and he has IMHA. We're hoping we get to talk with her today since he'll be moved from ER to IM. The other thing we have going against is that Boomer's vet is someone we've used for over 20 years but he moved to the local Humane Society a couple of years ago. Getting in to see him on short notice is impossible. We had a follow up with him scheduled for this AM but because Boomer's back at the hospital, that probably isn't happening. We need a vet that is more accessible given our situation. Good news is I think I found one and it's the vet I mentioned previously who had worked in California, Denver, and now here. She's out for several days now (a funeral) but as soon as Boomer is out of the hospital and she's back in, I'll get her completely up-to-date and bring Boomer to see her - she's been kind enough to talk to me on the phone several times and gave me great advice about the meds and gamma globulin treatment that was being recommended. Speaking of meds, a piece of advice she gave me was to NOT use generic cyclosporine. She said it doesn't release over time as evenly as the non-generic brands. She originally suggested Neoral but Costco had Gengraf and she was fine with that non-generic brand. Thanks for all the support and good input.

Cal Idaho

Cal, Sounds like you got the best emergency workup. Excellent diagnostics. This is the way it should go with these dogs every time, but sadly many vets miss some of these tests. A 7 yr old male is more prone to hemangiosarcomas so it's important to rule this out immediately. Transfusion trigger is definitely evaluated by several criteria not necessarily just a low PCV/HCT. This is true in human medicine as well. If the patient does not seem overly stressed by the low PCV and can be monitored 24 hours, then it is a wise idea to wait on a transfusion. They are great to get that PCV up, but they do carry risks of reactions. Subsequent transfusions are problematic because of this. Yes, cyclosporine comes as two different formulations, and they are not the same! I was one of the first people to use the new veterinary version, Atopica. In 2007 Dr. Dodds had told me to get Neoral, but there wasn't any in Rochester. My vet offered to me that they had Atopica on the shelf for dogs with allergies. I asked Dr. Dodds if this was ok and she was delighted by the suggestion. So from that point on Dr. Dodds has added Atopica to her list. I always recommend Atopica now because it is dosed by dog weight and comes in easy to use capsules. The tricky part is getting the correct dosages so you can decrease the dose gradually without going broke. I had to do a lot of math since Chance was 100 lbs. and he needed starting doses around 250mg. I didn't want to be stuck with a very expensive package of 100mg if I could avoid it. So for a period of time I used two 50mg capsules to get that 100mg. Be sure to check with the manufacturer. They often offer significant rebates through your vet. my best patrice

Patrice NYS

Interesting Patrice that the 50mg came out cheaper. Online I found the pricing to be around $50 per 15 count of 50mg, but the 100mg come out as $80 (saving $20). My vet offered to price match so I'm only paying $160 a month (for 2 boxes). Additionally, you can get 30 counts online for $155.99

Monet Sammamish

No, actually not cheaper. But if I couldn't use the 100mg capsules as the dose was reduced, they would have been tossed, so a big monetary loss. Buying 50mg and 25mg gave me more dosage combinations. I am just trying to get people to think ahead here on this forum about buying these expensive pill packs if they are only going to be using part of a pack. Get the smaller dosage so that you can use the whole pack. If you start with a dose of 100mg for example and are quickly reduced to a dose of 75mg then you have a partial pack of 100mg you can't use. In this case I would go with a pack of 50mg and a pack of 25mg. p

Patrice NYS

Thanks Patrice - I hadnt thought ahead to the weaning off cylco period. Gosh, sure hope I don't have to get something compounded with what we're using. BTW, I'm formerly from Batavia but left a LONG time ago (1980 - one week after graduating from high school)! Boomer just came home about an hour ago. He's holding steady at around 16% - so it's a waiting game now to see if the drugs stop his immune system before he needs another transfusion. Our biggest worry is how to tell if he's dropping too low. For now, it looks like we'll take him in for PCV checks daily and watch for any significant behavior change though he is now doing nothing but laying down. Poor guy - praying the meds start to work stat!

Cal Idaho

Boomer is about the same but has ate almost nothing - thankfully he ate a piece of roast beef that we had wrapped his pred and azathioprine in. We tried to give him everything we could think of: beef liver, boiled chicken, ground beef, etc - nothing worked. A couple hours later (on an "empty stomach") we have him cyclosporine for the first time ourselves (he got it twice at the hospital). He threw up within 1 minute (probably closer to 30 seconds. What he threw up was food he was feed at the hospital 14 hours earlier. How is that possible? Even stranger is I couldn't find the cyclo capsules in what came up. I got a fork and looked very closely and there was nothing. How is that possible? We have an appointment in the morning with the hospital internist - we'll see what she says. Biggest concern is that he is not eating. He's really not drinking much either but has taken a couple of small drinks in the 10 hours he's been home. I plan to use a syring to give him a bit of water through the night and hoping he'll eat in the morning.

Cal Idaho

Cal, Yes, with the prednisone he should be chowing down. Not the usual scenario. Is he being prescribed doxycycline? Sometimes they will do that as a precaution against a possible tick disease. If the tests have been negative for that and they are giving him doxy, ask if you can stop giving it. Digestive upset is the most common side effect of cyclosporine. This throwing up is to be expected for the first couple of doses but should diminish after a few days. I know Dr. Dodds would say that you should do what you can to help him keep them down and if that includes giving it with food for a few days, then do it. It certainly is better than losing the whole dose. Also Dr. Dodds had me dividing Chance's doses and giving one morning and one night. Are you giving the whole daily dose at one time? See if the vet will allow this splitting of the dose. Last effort would be to reduce the dose temporarily to get something down. In addition, Dr. Dodds had us pulse dose. We gave the cyclo monday through friday and no doses on the weekends. It was very effective with Chance and gave him a little drug holiday each week. Sounds like you are trying mostly protein sources? Try something different like a bit of cream cheese (they make salmon flavored, yum) Or a little bit of bread with some really good tuna or sardine inside. Make some balsamic rice with homemade chicken broth and bits of chicken so that it is really fragrant, warm and sloppy. He may be finding the fats in the proteins too much for his stomach right now, so this will give him some easy to digest carbohydrate. Yes, syringe the water multiple times a day. Prednisone will contribute to tissue dehydration and you don't want him to go there. my best patrice

Patrice NYS

Hi Patrice - Tick diseases here are rare - they almost apologized for doing the test but they wanted to elminate the possiblity, so no, he's not on doxycycline. We are splitting the dose of cyclosporine, AM and PM. And he's on a lower dose than they want him on long term. We'll ask the doc when we see her in a couple of hours if giving it to him for the first few days with food is ok. He ate a good breakfast this morning, about 1/2 cup of cooked chicken - couldn't get him to take his pred and azathioprine wrapped in roast beef so had to force it down. Eventually that worked after a few attempts and it came out on his tongue. I'm not going to like forcing these meds down his throat and I fear he's not going to like me.

Cal Idaho

Hi Cal, As usual some great suggestions from Patrice. Of course forcing pills down is the last resort, but if you have to do it, I developed a pretty good method. First and most important, don't stress about it, your dog will pick it up. Tell him what a wonderful dog he is. I open the mouth just slightly on the dogs left side and push the pill down as far as I can with my right thumb. It seems on the side they have less of a gag reflex than in the middle of the throat. Just my experience. 1/2 of a cup is a start! Good luck, Brigitte & the poodle boys

Brigitte BC

Try coating the pills in a little peanut butter. have you gotten pet-tinic if not it is highly recommended. Sending our prayers Cheryl & Ginger

Cheryl & Ginger Pinevile PA

You shouldn't have to force the pills down. If he won't take it with a coating (peanut butter, velveeta, pill pockets) then you can use the method that vets use. Hold their muzzle upwards, open their mouth, drop the pill to the back of the throat away from the tongue. Then hold the muzzle shut and wait for their tongue to poke out (that means they swallowed) No gagging, no forcing.

Monet Sammamish

I find what works best for Wylie is canned dog food, right now she is on a pretty big antibioticthe pill down her is almost impossible. Monets trick will not work for her, she will spit it out minutes later. So because the pill is so large I use about a TBSP of lowfat canned dog food, she laps it right up. So if your pills are smaller you can try a smaller amount of canned food. Good luck Laurie

Laurie Ca

Monet's trick doesn't work for me either! Both my dogs have mastered curling their tongue in the back of their mouths to block off their throats! I use Brigitte's "right thumb" method to bypass the throat block! Hopefully you had a good visit today and will see great results soon!

Sharon PA

Hi all - thanks for all the advice. Boomer isn't eating anything now but shredded chicken - I've tried all kinds of foods he likes that I could hide a pill in and he refuses them. We tried some peanut butter and he gave it a few licks and said "no thanks". So what we are doing and it does work is using a "pill popper" (not sure if that's the name or not) that the vet gave us. It's a device that has a soft rubber tube at one end and looks a bit like a long plunger. You pull it back to "load it", put it in the dogs mouth and push the end so that it "pops" the pill back. This has been less traumatic for Boomer than trying to put it back on his tongue by hand. My wife said she struggled for 10 minutes to give him a couple of pills - she didn't want to use the popper and gave up giving him 1/2 a pill that he needed. I used the popper for the first time and it was no problem. I think what I'm learning from this is that every dog is different - what works for some doesn't work for others - even when it comes to the treatment of IMHA. I guess that's what makes this such a hard disease to beat. I had said Boomer wasn't drinking much for us - found something that works for us. We were given an infant medicine doser - you know, those things that look like a needle but don't have a needle. Boom was refusing water from his bowl but just loves to drink water from the plunger. I just put it in front of his mouth and he starts to lick. So happy about that too. So he's eating warmed up boiled chicken and drinking water from a plunger. BTW, Boom's PVC was up slightly today from 16 to 17% which I realize could be lab error but I'm taking it as good news and praying that when we get the next PVC on Saturday that it's up again.

Cal Idaho

Congratulations Cal! You are a problem solver, it will get better every day. Good luck on Saturday, Brigitte

Brigitte BC

Cal, The important thing about the 16 or 17% is that it is stable, not going down. Very important. I have a recipe to make home made pedialyte. Ask your vet if they will approve of that for Boomer. The pills were very stressful for me too. It's not a natural thing to do with a dog. You are resolving this well. Remember, you are the adult, Boomer is the dog. You win. p

Patrice NYS

Boomer lost the fight with IMHA at 12:35 PM MDT today. We noticed an elevated heart rate and he was panting hard. I took him to the vet hospital; he was sitting on my son's lap in the front seat, climbed off onto the floor and shortly after that lost consciousness about 15 seconds before we arrived at the hospital. He was bleeding from his nose. They tried to bring him back with CPR but could not. Our family is devastated. Video of Boomer in happier times: http://www.youtube.com/watch?v=TMnFFdClO_8 All the best - Cal

Cal Idaho

Cal, Oh dear I am so sorry this has happened. Please accept my deepest condolences. patrice

Patrice NYS

Dear Cal and Family, Boomer had a wonderful life thanks to you. You tried everything in your power, but it was not meant to be. I just read an interesting article about the term loosing the fight with cancer (exchangeable with IMHA) This wording, loosing the fight, would mean Boomer (and my dog Kahlu) was a looser. Of course this is far from the truth. For what ever reason Boomer's journey was over. His work here was done. He was a winner, because he won so many hearts. It will take some time, but eventually the great memories you certainly have will replace the last bad days in Boomer's life. Hang on to those wonderful memories, Boomer will always have a special place in your heart. With sincere condolences, Brigitte

Brigitte BC

Dear Cal and family Please accept my deepest condolences in the loss of your dog Boomer. You did everything you possibly do for him and sometimes like Brigitte mentioned it was not meant to be. Try not to think of Boomer in sadness but remember the good times you had with them, and that he is happy now playing ball with many other wonderful dogs that have succumbed to this disease before him. Cheryl & Ginger

Cheryl & Ginger Pinevile PA

Cal and family, Please know how very sorry I am for the loss of your dear, sweet Boomer. This is just an awful illness. Remember that he knew how very much you all loved and cared for him, and I know that in time, your wonderful memories will help you smile instead of cry. Sally and Bentley

Sally Louisiana

Cal, I am so sorry for your loss. I just now came across your thread and I'm so sad that he made a turn for the worse. Boomer now is happy running around with lots of other pups, and will await to someday be reunited with his wonderful family. Our thoughts are with you Christina

christina new jersey

Cal & Family~ It's so hard to lose our beloved pets, no matter how... it's hard to let go. I'm sure Boomer was comforted by your loving care and you will be comforted by all the wonderful times with him. But now it is ok to cry. It hurts. And we hurt with you. May the LORD who created all living things, comfort you and surround you with HIS love. Blessings, Cindi & Tori

Cindi PCB

Cal, I am so very saddened to hear of the loss of your most beloved Boomer. Please accept my deepest sympathies on your loss. When you feel up to it, I urge you to visit the Loss & Grief page at the Meisha's Hope AIHA/IMHA Web site: http://www.cloudnet.com/~jdickson/loss.htm This page was written with input from those who have lost their dogs to AIHA/IMHA and contains many resources that will be very helpful to you during these most very difficult days. Once again, my deepest sympathies to you and your family on your loss.

Joanne MN

Oh that is so awful to hear and I am so sorry for your loss! At least poor Boomer doesn't have to suffer any longer. I could never make the decision to give up on Cookie, so I may sound hypocritical, but it's one thing after another for her and I think she would have preferred to not go through all this treatment.

Monet Sammamish

Cal: We are so very sorry to hear that Boomer passed away. You did everything you could but for whatever reason God decided that it was time for Boomer to join Him at the Bridge. We hope that in the coming weeks you can look back at the happier times and smile a little. Boomer is at the Bridge with some wonderful dog companions just enjoying himself while he waits for you. Rita, Mike, Greta and (angel) Sheba

Rita IA

This thread was discussed between 24/08/2011 and 27/08/2011

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