Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Big disappointment today. Opinions needed.

I need some opinions on this before I call my vet and challenge him tomorrow. Maybe I'm completely wrong... 7 weeks before being diagnosed with AIHA Ernie had to start on meds for his epilepsy. He's on 15mg epiphen twice daily and hasn't had a fit since he started meds so it's obviously doing the job. When he was diagnosed with AIHA both his red and white cell counts were very low which is apparently unusual, the vet expressed surprise at his white count being that low. He was started on 5mg pred twice a day and responded really well, within 2 weeks all counts were back within normal range. Since then he's been having blood tests at 2 week intervals. His RBC has been stable and within normal range every time but his WBC has been dropping. 4 weeks ago it dropped JUST out of normal range and the vet said it was caused by over suppression of the immune system and we needed to reduce his pred. In spite of the reduction his next test showed a dramatic reduction in WBC, and the vet again insisted this was due to pred and lowered his dose again. Today his WBC has dropped even further and to say I'm disappointed would be an understatement! Vet is still insisting that it's the pred and wants to do yet another reduction. Something about this made me very uneasy so I did a google search on drug induced neutropenia. I found a study of over 200 dogs and cats with neutropenia, 30 of them were suspected to be drug induced. Out of those 30, NONE of them were on pred but 5 were on EPIPHEN! To me that kind of suggests that the epiphen and not the pred could be responsible for his neutropenia. It would also explain why his WBC continues to drop in spite of the reductions in his pred dosage. I don't relish the thought of having to challenge the vet yet again, he didn't take too kindly to it last time, but Ern's WBC level is now serious and getting worse in spite of the reductions. Does anyone else agree with my thinking here or am I just being paranoid? Tomorrow I'm going to call our old vet and get her opinion, but in the meantime I'd appreciate any input. Here's the study I found if anyone is interested www.jaaha.org/cgi/reprint/37/2/131.pdf

Sue Northants UK

Sue, I think you need to talk to someone who hears your concerns and is open to the possibility that you could be right. You need to have confidence in whomever is treating Ernie and if you have to exhaust yourself trying to make your points it is time to find another doctor. I was very fortunate to have an ER Vet that welcomed all my input and anything I asked that she couldn't answer or was contrary to perhaps her way of thinking she did put it out to other collegues to be able to present the most informed choices. You don't have the luxury of being wrong on this so don't worry whether your Vet likes it or not. Keep us posted. Penny

Penny Lytle Creek Calif

Sue, I agree with what Penny has said about needing a vet that is easy to talk to and open to discussing Ernie's treatment. You have enough of a challenge coping with Ernie's health issues without having to worry about offending your vet. I have no experience with epiphen or canine epilepsy but just out of curiousity I looked up the side effects of epiphen. Guess what - neutropenia is one possible side effects. Here is the website I was at: http://www.canineepilepsy.co.uk/VetRecource/penobarb.htm Hope this information helps. You are Ernie's advocate and you aren't doing anything wrong by speaking out for him if you have a concern about his health. Your vet should listen. Please let us know how it goes and good luck! deb and Duck

Debbie BC Canada

Sue, How low is Ernie's WBC? I don't have experience with Epiphen but Murray's WBC dropped dangerously low as a result of the immuno-supressant drugs he was on at the time (he had been on Pred ~10 weeks, Imuran ~6 and had just started Cyclosporin the week before). We picked the low WBC up on one of his routine labs and the internist treating him at the time dismissed it because it wasn't that far out of range and told us to keep going with the combination therapy. About a week later, he became acutely ill and was hospitalized b/c he had developed a bacterial infection his body could not fight and he was septic. At that point, I switched internists and he was pulled off all his IMHA meds (except a maintenance dose of Pred) in order to give his immune system a chance to respond and get to a level where it could fight the infection. It was very scary stopping everything at once but he became so acutely ill in a matter of hours, we felt it was our only chance to save him. It's the double-edge sword of most meds - not many are without side effects but sometimes the benefit outweighs the risks and vice versa. So, it certainly may be the Epiphen but, depending on where Ernie's at, you may have to reduce both to some degree. I think you are absolutely right to keep a close eye on it. And, I completely appreciate your feelings about your vet - I wish I would have pushed the first internist more when we first picked up the drop because we might have spared Murray a lot of pain but I had never heard of this happening to anyone. Best wishes for you and Ernie - Bonnie

Bonnie Chicago

Thanks to all for the input. And thanks for the link Debbie, I've added it to my wad of printed material to take to the vet this afternoon. I found another short piece after making this thread last night which added to my suspicions..... """Department of Small Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens 30602, USA. Three dogs became lethargic and had poor appetites within 2 months after anticonvulsant treatment was initiated to control seizures. Dogs were neutropenic, thrombocytopenic, and anemic and had splenomegaly. Sensitivity to phenobarbital and related anticonvulsants may induce life-threatening leukopenia, thrombocytopenia, and anemia in dogs. Phenobarbital-induced neutropenia in these 3 dogs may have posed a risk for developing bacteremia. It is important for clinicians to be aware of adverse effects so that adequate precautions can be taken. A baseline hemogram should always be obtained before starting anticonvulsant treatment, and periodic hemograms should be obtained to monitor animals. Furthermore, client education should include instructions on recognizing signs of bacteremia, thrombocytopenia, and anemia.""" Ern first became sick 6 weeks after starting on phenobarbital. On 2 mornings in one week I came home from my nightshift to find him lethargic, shivering, confused and with no appetite. Since this is his normal post seizure behaviour pattern I assumed that he'd had a fit during the night. The only thing that made me doubt it slightly was the absence of urination/defecation/vomiting, but I just thought it had maybe been a very mild seizure. On advice from the vet I doubled his phenobarb dose. Ern seemed to deteriorate but they always need time to adjust to a new dose so I sat it out for the recommended 10 days. Wasn't happy with it at all so I spoke to the vet and dropped his dosage back down. Another 10 day wait for adjustment and he seemed to have improved slightly, but still wasn't right. Having already wasted 3 weeks on dosage adjustments I took him to the vet where he was found to have a high temperature and was treated for an infection. After a week on antibiotics he was deteriorating and at that point he was admitted for the whole round of tests and the diagnosis of AIHA was made. When he started on pred he improved pretty fast and held stable on 5mg twice a day. (did the pred do something to couteract the phenobarb reaction?) As soon as we started the pred reductions his WBC started dropping. Each reduction has resulted in another drop and his WBC is now at 2.5 This all seems like too much of a coincidence to be ignored. If there is even a remote chance that the phenobarb is responsible then I want him taken off it, there are other anti-convulsants he can have. I'm off to see the vet this afternoon armed with a wad of print outs. If he's unwilling to consider the possibility that he might be wrong than there are at least 3 other vets I know fairly well who would give me a second opinion. All vets who have treated my animals in the past, sadly all quite a distance from me now. But if I need to travel further to get the best treatment for him then so be it....

Sue Northants UK

Good luck this afternoon Sue, I have only now checked in so can't offer you any advice before you go to the vet. I wouldn't offer you advice on something I know nothing about. Our vet is very matter of fact and we suspect wouldn't take too well to be challenged, but challenge I did when Jaspers hemolysis returned. She wanted to keep him on the same dose for a month whereas I didn't, I wanted it put up slightly, which she agreed to and to be honest she was fine about it. We know our pets better than they do and if they are good vets they will surely listen, and be prepared to accept they have made mistakes..... they too are on a learning curve with AIHA aswell as other diseases. Good luck, we will be thinking about you, Jackie and Jasper.

Jackie pembrokeshire; west wales; uk

Good luck, and go for both the challenge and the second opinion. I know it's hard to challenge a professional, but all possibilities need to be checked and eliminated. Hilary

Hilary Hampshire

Typically, both the vet treating Ernie and the vet I wanted to ask for a second opinion are on a day off today and I've left messages for both of them to call me tomorrow. In desperation I emailed Dr Jean Dodds with a detailed history of everything that's happened to Ernie since he started on the phenobarb. Much to my surprise I got a reply in less than half an hour! She agrees that the phenobarb could well be the cause of the problem, and recommends that he be switched to an alternative anti-convulsant as soon as possible. Continuing on pred until his blood counts are all back to normal, then reducing or even stopping it once he is stabilised and the phenobarb is out of his system. I know I've still got to persuade the vet who is treating him, but I've added her email to my wad of print outs and one way or another I'll find a vet that will listen! I'm not sure if this means that he DOESN'T have AIHA after all, or if it's still AIHA but with phenobarb as the triggering factor. I don't suppose it actually matters that much, either way he needs to come off it.

Sue Northants UK

Sue, sorry to hear you are having to go through all this! Thank goodness you didnt have to wait long to get a reply to the e mail you sent. Keep us posted on what your Vet has to say about all of this. Speaking of Vets, mine was supposed to call me back with the results this evening, I did call twice as a gentle reminder, he was busy and would call me when he finished at 7, hmmmmmm it's 8 pm now!! Guess he forgot. Tricia x

Tricia UK

ur vet should welcome being 'challenged' because in essence it shows that you have an interest in the dogs health (because that is all that should matter) and that you are a good owner. ...any vet that has an ego too big to put the dogs health at risk in order to satisfy it isnt a vet i would want my dog visiting.

josh california

Sue, When I asked my vet if they would be willing to have Dr. Jean Dodds input treatment advice, she looked surprised (that someone that famous was actually involved) and then gave me a big and gracious smile. It might help you if you approach your vet with gratitude for all of his clinical background and expertise in nursing care.... And then ask him if he would be willing to accept outside treatment advice from Dr. Dodds. If he still is recalcitrant, then you will have to find either another DVM at the same office or another office. You still need access to expert nursing care, meds and someplace to go in an emergency besides the routine cbc's etc. I trusted Jean with Chance's life and I am very grateful that he has survived what seemed to be a death sentence. You need to find a higher power that you can trust right now. Jean has been my higher power for many months now. Love, patrice

Patrice New York State

Sue, Keep questioning your vet, its too bad if he/she doesn't like it....as a parent you only have you babies interest at heart. I had to challenge my local vet here on many occasions as it was too far to go see the specialist everytime. And wouldn't you know it, when she would "double check" my suggustion with that of the specialist, she'd end up eating her own words. Now, she listens to what I have to say without further problems and often chooses the course of action that I have indicated that I want/or that I feel is best. If your vet is not willing to bend, find a new one -- I guess they don't need your money anyway. Good Luck! Jenelle & Monster

Jenelle Pueblo

This thread was discussed between 03/12/2007 and 06/12/2007

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