Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Bone Marrow Biopsy? please help!

Please help. My dog Gracie was diagnosed with IMHA last monday. She was started on the pred and sent home. Her PCV levels dropped down to 9 overnight and she had a blood transfusion which brought them up to 30. For the next 4 days her PCV hovered around 23 so she was sent home on sunday and ordered to have another retic test since those numbers are extremely low and dropping. 2 days after being home, her PCV is up 2 pts to 25, but her retic count has dropped down from 9700 to 6700, which is telling us she has non regenerative IMHA. The specialist wants to do a bone marrow biopsy, but her vet thinks its too risky and painful at this point. She thinks since her PCV is stable (and actually increased) we should hold off and let the meds do their job. She was diagnosed on the 18th and started on the pred, and finished her blood transfusion on the morniing of the 21st. Its now the 26th and the specialist is pushing for the bone marrow test. All her other blood work, tic test, x-rays, etc are all normal. I am hesitant about the bone marrow biopsy. I am afraid she could possibly die during the procedure or experience a lot of pain and it won't bring us any closer to telling us whats wrong. Can some one tell me if I should have the bone marrow aspiration/biopsy and risk it or wait and see if the meds will work? Her vet also suggested putting her cyclosporin (sp?) in addition to the pred. Is this something I should do? Please Help. Morgan

Morgan Chicago

Morgan, We were in a similar situation faced with the same decision. I opted not to go with an invasive test for my 9 1/2 year old cocker spaniel. Turns out, it was a good decision in our case and the drugs did begin to work. Others on this forum made that same decision, and others opted for the biopsy. Each case is different, and hopefully more will weigh in on their experience. Sharon

Sharon PA

Morgan - hi, I saw your note and am sorry you and Gracie are going through this. How old is Gracie and has her health been otherwise good? It sounds as though you have good counsel from your regular DVM, which is great. I am in Chicago as well - what specialist are you seeing? Only you can make the decision on whether or not to do the biopsy based on what you feel isi right for Gracie - no two dogs seem to handle this disease or the treatment the same. But, here is our story and I'm sure others will chime in as well - My dog was diagnosed in March 2007. We went through all the diagnostics to rule out possible causes of the anemia (ultrasounds to look for tumors, blood tests for tick disease, etc.) and, lastly, the specialist recommended a biopsy to look for cancer at the level of the marrow. I remember at the time, he told us that we could treat him for IMHA with no biopsy but if we ever thought we would not put him through the drug protocol if it were cancer, then the biopsy would help us know that. At the time, I knew NOTHING about this disease or the protocol but I was worried about putting Murray through anything if it would not help him. The specialist assured us the biopsy was quick, safe, and was not painful. Based on his assurances we went ahead. And, honestly, I have regretted doing it ever since because the procedure was definitely painful for Murray and has had lasting effects (four years later he has a large growth at the biopsy site - I really feel as though he mis-led us. The biopsy did not show cancer but it didn't definitely confirm IMHA either - the results led them to conclude Murray had non-regenerative IMHA at the level of the bone marrow - the pathologist saw some precursor cells but did not see the actual destruction in the sample. Net - the treatment protocol was the same as it would have been otherwise. I'm not sure biopsies are considered important in the treatment of IMHA. I'm sure several others will chime in with their knowledge and experience. I don't mean to discourage you - you need to do what you feel is best for your girl - if she is a good candidate for anesthesia and you are at one the area specialty hospitals where they have current protocols, the procedure in and of itself should be relatively safe for her. Best of luck - please let us know how Gracie is doing. As I'm in the area, I'm happy to share any information with you that may be of help - just let me know. Take good care - Bonnie

Bonnie Chicago

Morgan, I am so sorry that Gracie has been diagnosed with this awful disease. I don't know if you have found Joanne's site yet? http://www.cloudnet.com/~jdickson/ It will answer a lot of your questions in language you can understand. Be sure to read the success stories while you are there. Penny

Penny Lytle Creek Calif

Hi, Morgan, I am sorry your pup has been diagnosed with this....but glad you found this forum. We are pretty new here, but these folks have been a wonderful help for us! They have helped me know this can be a journey of many small baby steps (thanks, Sharon) My Bentley also had a bone marrow aspiration at the beginning of his illness....I followed the recommendation of the specialists at our University Teaching Hospital here, and they did the testing (along with other blood work, xrays, etc)....cancer was ruled out, and the test showed no other problem with Mr. B's marrow. Like Bonnie, I wanted to know if cancer was what we were looking at, so it answered that question. It wasn't conclusive for IMHA, but all other symptoms pointed to that, and his treatments began. Bentley came through his bone marrow test just fine, with no lasting problems. So I don't regret doing it with him. Like the others have said, each dog is different....I would make this decision again for Mr. B and one of my other pups. The third dog I own, I'm not sure she could take it.....very delicate little girl! Bentley didn't respond to the prednisone alone, and the vets added cyclosporine to his meds after a week....we've since had to up the cycle dose a bit, and add mycophenelate....He's had two transfusions, and his numbers last Friday finally looked a bit better (3 weeks after diagnosis) He was also non-reg until his PCV got above 34. So it can take time and med tweaking to get a response. We go back tomorrow for a recheck. So far, the only side effects we're having are loose stool and a bit of muscle wasting....I think he's tolerating meds very well. He's also on sucralfate and Pepcid AC to protect his belly, and Denamarin and Pet Tinic for supplements. Don't know if this helps at all....you know your pup best of all. I'm sure you will do what is best for her! Sending you both big HUGS, and please keep us updated on how she's doing. Sally and Bentley

Sally Louisiana

Thank you for your responses, I really appreciate all of your input and am so saddened your dogs have gone through this as well. Gracie was a rescue, so although we aren't sure of her exact age, we think she is around 3. I have had her for about a year and half and so far she has been extremely healthy and happy, no issues until this came about. I have read a lot of stories about dogs with this disease and i'd say 90% of the stories I've read, the dogs have received bone marrow aspirations/biopsies and I haven't heard any horror stories about dogs not making it through the procedure, but I have read quite a few stories like Bonnie, who regret having it done. I am afraid I am going to make the wrong decision. My vet just happens to be my best friend since we were 5 years old, so I know she is in the best hands possible, it just makes me uneasy when not all of the vets involved in Gracie's care are in agreement on what to do next. I know my vet is treating gracie as if it were her own dog, so I am inclined to trust her more than I would just any other vet, however the truth is she has only been out of vet school 2 years and is not a specialist. The good thing about it is she is able to call her friends from vet school around the country and get the opinons of the specialists at their clinics as well. So far, one specialist in Boston and one in NY have both advised not to do the bone marrow until the meds fail and her PCV starts coming down. They have all advised it still might be too soon after the transfusion to do such an invasive procedure. They also advised me that in the majority of the cases, the treatment won't change after the biopsy anyways. I have made an appointment at another area specialty clinic just to have all her charts looked over and get a second opinion on what my next steps should be. I hate watching Gracie go through this, and I constantly find myself checking and rechecking her gums, her breathing, etc... I am worried at any moment her PCV could drop again and send us back to the hospital. Bonnie- initially she went to VCA aurora at the recommendation of my regular vet. We have an appointment on friday at Buffalo Grove Specialty clinic for a second opinion. Please let me know where you think is best.

Morgan Chicago

Morgan, Sounds like you are doing a marvelous job for your sweet girl! My regular vets, two ladies I adore, have been practicing about 10 yrs, but between the two of them, had only seen about three cases of IMHA. So they sent us straight to LSU Veterinary Teaching Hospital to a specialist. Now, Mr. B has THREE vets working on him, and all are in constant contact. Your vet (and friend) is obviously doing a great job of getting info and advice, and I think the more info you have, the better to make good decisions. You know what I keep telling myself? That I'm making the best decisions I possibly can for Mr. B with what I know....maybe not perfect, but the best I can. And please know I too am going through that "waiting for the numbers to drop and go back to the hospital" thing....it seems to be a common thing with this illness. Do watch her tongue and gums, and remember to give lots of hugs and puppy kisses :) Please know too, that you aren't alone....that has been one of the biggest helps from this forum! Sally and Bentley

Sally Louisiana

Morgan - It would be my dream to have a veterinarian as a best friend! Seriously, it sounds like you and Gracie are in good hands as her doctor is willing to reach out to others for opinions and experiences. I'm not familiar with the internists at either hospital you mentioned; from the locations, it sounds as though you are in the western, north-western suburbs? I'm on the far north side of the city so we saw doctors on the north shore and city. For what it is worth, in my opinion, the "best" doctor, whether board-certified or not, is one who has experience with this disease (or is willing to reach out to those who do) and one who you feel comfortable working with (i.e., they seem to you to have Gracie's best interest at heart, they are willing to answer all of your questions, consider your concerns). If you ever want it, I'm happy to share our experiences - we worked with two internists (ended up switching "mid-stream" which wasn't ideal but in our case necessary) - to see if either of them may be a fit with what you are looking for. Also, if you haven't looked into them already, I've heard good things about Arboretum View hospital in Downers Grove but have no personal experience with them. Also, I would suggest you Google Dr. W. Jean Dodds - her organization is Hemopet/Hemolife. She is based in California but recognized as one of the experts in immune-mediated diseases. Many of us have worked with her and she is willing to review medical records and work with your regular DVM on a treament protocol for IMHA (her fees are extremely reasonable and are tax-deductible donations to her non-profit organization). With respect to the biopsy, if you are still unsure, I would ask the specialist why they believe it to be necessary, if it will ultimately lead to any different treatment for Gracie and what the downside of waiting would be. In my experience with Murray over the years, some specialists are heavy diagnosticians and need to have "the answer" even if it doesn't affect their treatment protocol. Someone recently gave me a great piece of advice; she said (I'm paraphrasing) "sometimes all the specialists can do is recommend the next test - it's up to you to decide if that is in Murray's best interests". At least for me, this has been helpful in deciding next steps for Murray. Take care, Morgan and let me know if there is anything I can do to help. I remember how relieved I was to find this board several years ago. Best Regards, Bonnie

Bonnie Chicago

Hi Morgan, Very sorry to hear about Gracie. Unfortunately there are many of us here who know exactly how you feel. Although I would love to be able to make it easy for you, this is not an easy disease to fight. Cases vary so much. Unfortunately there are several reasons why the bone marrow may not be regenerative. I suggest you do 2 things that muight get you more help from people who know a lot more than some of us newbies. I sugest you post your dog's weight and the exact doses of drugs and when they were changed. I also suggest you post more than just pcv. White blood cells, platelets, etc too. Anything else of significance may help. Also, I suggest you contact Dr. Dodds, hemopet @ hotmail.com (remove the spaces). She can provide your vet expert advice as she as helped many, many dogs with this, far more than most vets and specialists, as she gets so many referals (she started hemopet, the canine blood bank, amongst many other things). She is well known and in the short 4 months I have been here, she has donated blood and so much time for free to help every dog and owner who asks. Many times the biopsies have shown nothing from what I have seen here (Short time though) and are clear of cancer. In the end, suppression of the immune system, even though it may take a while has worked for many of the people here, but in those cases it is AIHA/IMHA, often at the precurser cell levels and it takes a while to respond to meds. Again there are other things that can impact the bone marrow, so I do recommend specialist care, like Dr. Dodds can provide. Unfortunaely there are no clear answers until after you have made your decision and even then sometimes not. I certainly wish you the very best in your fight and will try to help anytime I can. Try to take it one step at a time, ask questions whenever you have one and make deicisions with the best info at hand. Multiple opinions, even when they conflict are not bad as long as everyone has the same goal, to help Gracie. Sorry I cannot be of more help, Richard & Dog Dylan

Richard Burnaby

Thank you Sally and Bonnie for your kind words. Everytime I read a post, it brings tears to me eyes and still am shocked that this is even happening to us. I agree that I have to remember I am making the best decisions possible that I can at this point in time, but I just wish I could do more for her. I have read some info about Dr Jean Dodds, but how would I get in touch with her to have her look over Gracies stuff? Bonnie, my vet basically told me the same thing you did, that some of the specialists are all about diagnostics even though it might not even change the treatment, so while I am still waiting for the specialist at the VCA to call me back, the more I read about this disease, the more I am shying away from the biopsy.

Morgan Chicago

Thank you Richard, I will definitely contact her. I appreciate your help and advice. Any knowledge I can learn from people who have gone through this is definitely welcomed. Once I get copies of the rest of her blood work, I will post as well, so far since being diagnosed a week ago, she has lost 8 lbs which brings her down to 42lbs, she has been taking 20mg of prednison and 100mg of doxycicline twice a day in addition to pepcid ac. so far, thats all shes had. nothing has changed in her meds since diagnosis. Her Retic count at diagnosis was 14900 and is now at 7600. I know her white blood cell count is high, which her dr said is normal since she is fighting this. Once I get the particulars I will repost. Thanks again for your help. Morgan

Morgan Chicago

Morgan, I know just what you mean about being shocked too....I was the same way when I heard Bentley's diagnosis. Now I'm learning just how many dogs (and cats) IMHA has impacted. I should have mentioned Dr. Dodds too! I emailed her as well, and received a reply the same day regarding Mr. B's treatment. Mr. B's Absol Retic was also very low (non regen) but after three weeks on meds, went up to 115,700....once his PCV hit 34, it dropped back down, but the meds did boost it when his PCV was lower. His white count was also very high, but is now much lower. So Gracie may just need more time for the meds to start working. Or like my vets said, meds can be tweaked. Is she eating? To help Bentley a bit, I started giving him some boiled chicken and rice, plus a bit of canned pumpkin for his belly. He eats three smaller meals a day so its easier on his tummy, and he gobbles that down. He's actually gained a little. Everyone here suggests keeping diet lower fat to ease pressure on the liver....some here even suggest baby food if the pup is fussy about eating. I'm learning more and more about this every day too...and its quite the learning curve!! Happy to help any way I can....Oh, and if you're on Facebook, there is an IMHA page on there as well. Sally and Bentley

Sally Louisiana

Hi Morgan, I think you would probably get advice here that the prednisone dose is on the low side. Although 1 mg/pound daily is suggested, lately I see mostly 2 mg/pound and certainly plenty of advice to raise it to 2 mg if it is not taking effect. I would support that too if the side effects indicate low, or moderate reactivity. If you are seeing excessive drinking, peeing, or aggression, or other behavior that is not normal, this is likely the effect of prednisone. Panting? That is what prednisone does when it is taking effect, as it increases metabolism. If you are not seeing these signs, or they are only minor, you maybe should consult the specialist, or Dr. Dodds about this. It could mean a low sensitivity and a higher dose is warranted. She also adds cyclosporine, from what I have read. Patrice posted her protocol for non-regenerative anemia on Christina's "Aplastic Anemia" thread. Please remember to consult your vet with anything from here. And Dr. Dodds if possible. She also posted some good descriptions on Sally's first thread "Hi -- My pup Bentley just diagnosed". Patrice is very informative in those threads. I have normally seen vets prescribe 2 mg per pound and higher (divided over 2 doses per day) on this list and if a dog is very reactive (like my Dylan) this is too much, but in some dogs, they do require more and it can be given at these doses, I just would not want to keep them there long, especially if they were very reactive to it, like Dylan. Once again, feel free to keep asking and good luck to you both, for sure, Richard and Dylan

Richard Burnaby

Morgon, I am so sorry to hear of your Gracie's IMHA diagnosis. Many times, Prednisone alone will not be enough to get a dog with AIHA/IMHA into remission. Other medications such as cyclosporine and/or Azathioprine are used very often in the treatment of AIHA/IMHA. If you have not already visited my Web site on Canine AIHA/IMHA you might want to do so when you can. The URL is http://www.cloudnet.com/~jdickson/ The treatment page has links to other pages that have info on cyclosporine and azathioprine. you will also find these medications mentioned many times on the Success Stories pages. Not only will these stories show you what has worked for other dogs in terms of treatment options but they will give you lots of HOPE and show you that dogs can and do recover from AIHA/IMHA and go on to life Happy heathy lives. Be assured both you and Gracie are in my thoughts and prayers during these most very difficult days.

Joanne MN

Richard, she is definitely showing the signs of the prednisone. She is an eating, drinking, and peeing machine lately, and is panting excessively as well. I talked to her vet this morning and she wants to start Gracie on the cyclosporin tomorrow when she gets her next pcv and retic test. In the mean time, I am still getting calls from the specialist pressuring me to schedule the biopsy. I am still unsure at this point. Id like to give the medicine time to work before she is subjected to more procedures. Joanne- your website was one of the first I came across when she was diagnosed and it did give me hope reading all the success stories of the dogs, but also showed me that we are definitely in for the long haul in dealing with this disease. Please continue to share any knowledge you can with me as I post Gracie's progress. I really appreciate it.

Morgan Chicago

Morgan, I sm so sorry to hear about Gracie. I don't think I would do the marrow aspirate after reading over the years here the porblems with it, and like your thoughts let the drugs kick in. Make sure your vet recommends that cyclosporine not to be given with other drugs, it's something like an hour before or after the other drugs kick in. Laurie

Laurie CA

This thread was discussed between 26/07/2011 and 27/07/2011

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