Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Brigitte on the rollercoaster! Help please!

Hi everybody, Kahlu seemed a bit low tonight and before going out and leaving him with my husband I checked his gums. They were clearly MUCH whiter than a few hours ago. I called the vet and she met me at the clinic. Before she got there Kahlu had water thin diarrhea. He had a thorough check, that did not reveal anything other than small ulcers on his lips and whiter than usual gums. The ulcers clearly from the prednisone. When we got the blood check results we both could not believe it. His PCV was up again from Friday to 37! RBC 4.4. We looked at his gums again and they were clearly much pinker again. The vet came to the conclusion that it is his gut bothering him. He is on 45 mg pred. 2x per day. His weight fluctutes between 52- 54 lbs. The vet suggested to give him only 30 mg tomorrow morning and then 45 again at night. What do you think? Also if his diarrhea is not better in the morning to put him on a small dose of metronidazole. He is also on Sucralfate, ranitidine and misoprostol. The vet will call me tomorow morning, any suggestions? Thanks so much for your help! Brigitte

Brigitte BC Canada

Wow, what a scare! You are right, it is a roller coaster. Several months ago, someone here, I think it was Patrice, enlightened me to resting anemia. That is, when they are very tired and relaxed, like at night and in the morning, their gums can go a little pale, then after breakfast, water, a walk, etc, they just sort of perk back up. Scary stuff, I know! Tiggs still has really pale gums at night and in the morning, and he is in remission, so I totally understand the panic. Try to focus on the clinical signs. For sure, diahrea can also dehydrate them a little, which could also cause the pale gums. A lot of times, especially in the beginning, their tummies are really upset. You can try adding boiled white rice, and also canned pumpkin to their food to help with the tummy stuff and diarhea. Pumpkin can also help when they are constipated, it's a great little trick that I learned from others here on this board. To me, I would be cautious about lowering the dose, but I'm not a professional, or a vet. Just my own personal thought. Best of luck, I hope things continue to improve. Melissa and Tiggs

melissa slc

Brigette, I am so sorry you had this scare tonight. It was good that you followed your instinct to have him checked. A PCV of 37% is right at the low normal level. My dog Chance never gets much above 38% or so and does quite fine with that. But each dog has a different physiology and some breeds require a much higher PCV to be considered normal. That said, the color of the gums and other mucous membranes will normally wax and wane during the day. The RBC count is a bit lowish, but not terribly so. After a hemolytic event the body has to begin making a whole lot of new red blood cells. It starts in the bone marrow with baby blood cells called reticulocytes. In dogs or humans with a normal pcv, the maturation process mostly occurs in the marrow and the new blood cells are released into circulation after about 3-4 days. In a dog or human with anemia, the body will send these reticulocytes out earlier in an attempt to provide the body with oxygen carrying RBC to compensate for the low number of circulating RBC. These new cells still contain the RNA from the process that the body uses to make them. This shows up on a blood smear as a larger cell than the RBC's and with a blueish shape that is the RNA. An automated analyzer will record the number of these reticulocytes as being a different cell than the RBC's. Thus, the lower number of RBC's Kahlu's test may be showing. If those reticulocytes mature the number may rise in the next few days. This dose of prednisone is high, it's as high as we were giving Chance at nearly 100lbs. However, it is pretty close to the recommended starting dose. How long has he been on this dose of 80mg a day? If you have been on this for over a week and your vet has added or is planning on adding another immunosuppressive drug such as Imuran or Cyclosporine, then the prednisone can be lowered VERY SLOWLY over the next month. The general rule of thumb is once you reach acceptable PCV, decrease by no more than 1/4 to 1/3 of the original amount and precede each decrease by a full CBC. Maintain this dose for at least 2 weeks but preferably a bit longer. To come down from the dose you are using will take a very long time, if I remember how I did it with Chance. You are decreasing from 80 to 75 mg a day and that is a very moderate dose reduction. It sounds very much like what I did once I added the cyclosporine. Your other drugs are also good, protecting the stomach and preventing ulcers. The metrondiazole is a good drug for the diarrhea. I have used it with Chance on a long term, low dose basis to resolve issues like this. There are some possible side effects, discuss them with your vet. Prednisone is a very hard drug to take and the side effects can be dreadful. But it is necessary right now. Make sure you are giving it with food. Make sure that your other drugs to support stomach health are not given at the same time as food or medicine as they can interfere with absorption. Sucralfate is best given either late at night before bedtime or with several hours between it and meals. My best advice would be to continue to get routine CBC's done at least every two weeks, but if you can afford it, every week right now. Learn to read the numbers (keep your own copies) and follow the progress each week. You will learn to see the trends. Also, for right now, check the color of gums, mucous membranes of the eyes and the ears several times a day. You will begin to see these small fluctuations of color during the day and it will become less frightening to you once you see this is normal. After a while, you will get good enough that you can glance at the ears and tell the color. Try to get some sleep tonight and not worry too much. patrice

Patrice NYS

Melissa, thanks for the pumpkin advice, I will give that a try for sure. Patrice, thank you so much for the detailed info. He has been on the prednisone 90 mg per day in two doses since his diagnosis January 24. so 2 1/2 weeks. I start to think that that was too high. Reading about Imuran and Cyclosporin on this board, I have mentioned it to my vet, she knows about the drugs, but felt that if he is responding to the prednisone, that alone should be ok. Should he still go on these other drugs? I am a bit confused, but still relieved I took him in. By the end of this AND THERE WILL BE AN END! Kahlu will be showing me his gums on command! Thank you for your help, I better go to bed now, Brigitte

Brigitte BC Canada

I am bad at math at the best of times, but under stress I am even worse! I went over the all the pills I am giving Kahlu thinking this prednisone dose is way to high according to what I am reading. So turns out I am giving him 75 mg per day in two doses, not 90 mg. In my mushy brain 3/4 of a pill ended up being 45 mg...don't ask. 75 mg is still on the high side of his weight (54 lbs/25kg) I guess but better than 90! Maybe I can sleep now. Brigitte

Brigitte BC Canada

I am just back from the vet. after I told her that I was reading that maybe Kahlu should be on the prednisone for 4 weeks before reducing, she did some rethinking. She is just worried about his gut now. So she came up with the following. Reduce the daily dose from 75 mg to 70 and also give metranidazol 2x 125mg per day. What do you think? I also realized, that my vet who I love and know she knows lots, is not quite as familiar with AIHA as I first thought. Seeing a specialist is not realistic for us, because we live on Vancouver Island at least 4-5 hours away from the next bigger center, including a possible 1 1/2 hour ferry ride. So any advice from this board is very appreciated!

Brigitte BC Canada

One more thing I forgot to add. His WCB as well as MCV 82.2 NEU 38.81 MONO 3.35 and BASO 0.46are high. Are we missing something? Or is that normal with this disease? I only know what the WBC means, the rest is Spanish.

Brigitte BC Canada

Hi Brigitte, Most protocols call for a reduction of about 25% every 2-3 weeks of stable disease. So, PCV holding somewhat steady. You definitely want to take that slow. As for the rest of the blood work, google canine CBC's and you'll find the normative ranges for CBC. From what I can tell, the mono and baso seem within the normal range, and the neutrophils seem low, which could be because alot of the drugs suppress the bone marrow, which is where many of these cells are produced. You just want to watch the numbers because many of them can indicate infection. Patrice I'm sure will have great advice, she's very knowledgeable about all the different cells, what they do, etc. I just google, and try to make sense of it all. Funny, I'm married to a molecular biologist, and he's not much help ;) Try the boiled white rice and the canned pumpkin, I bet that will help the diahrea and help calm his belly, poor guy. My vet isn't a specialist, but she is wonderful, and she did on my request, consult with Colorado State University, who we did see eventually for another opinion. They were both on the same page, and communicated regularly. In addition, my vet has consulted with a local Internal Med doc when necessary, so if your vet is willing to just consult via the phone, I bet that would help! Also, if it's at all helpful to you, Tiggs initially was on 120 mg of pred a day (he weighed 65 lbs at dx). He got 3 20mg tabs twice a day. Now we are on 5mg every other day, but it's taken 7 months to get here. Lastly, are you guys on Azathiaprine? That drug is another immunosuppressive that is usually tried as well, in conjunction with Pred, because though it takes several weeks to work, it's generally easier on them and has less side effects. It is a bit harsh on their liver, and some dogs don't tolerate it well, but it has worked well for Tiggs. Good luck, melissa and tiggs

melissa slc

Brigitte, So sorry to hear that Kahlu is having a bad bout of diarrhea. I think the canned pumpkin with for sure work, but just make sure it is pure canned pumpkin and not the mix for pies. Our little chihuhua just had a bad bout of diarrhea, stomach virus, last week and we gave it to her and it stopped it. We gave her a teaspoon, because she is only like 12 lbs, in the morning, lunch and dinner for about 3 days. Linda

Linda Sapphire

Brigitte, "His WCB as well as MCV 82.2 NEU 38.81 MONO 3.35 and BASO 0.46are high." The WBC are the white blood cells and the most common reason they are high is some kind of infection in the body. NEU are neutrophils, the greatest number of WBC. Monocytes and Basophils are always in smaller numbers. Each type of WBC has a specific job to perform for the immune system. At this point your vet should have seen these higher numbers and the first thought should have been infection of some kind. There are other causes also. Seeing some basophils *may* be indicative of the body attempting to fight off a tick or heartworm disease. The best way to find that out is to make sure your vet ran the routine in-house test called SNAP DX4. I would be surprised it they haven't done this already. MCV is mean corpuscle volume. What this really means is the *size of the red blood cell.* When a dog is anemic and the body responds by making new red blood cells, these cells can be a bit larger than their older "cousins" already circulating. So this number is probably indicative of a regenerative state following anemia and is most likely the cause of the higher number. This is generally a good thing. It can sometimes indicate a B12 and Folate deficiency. When MCV is paired with the amount of hemoglobin inside the cell (MCH), it really tells how good a job the RBC are doing carrying oxygen. This value is listed as MCHC. Clinicians use these values to sort out the causes of anemia. For instance a smaller than normal red blood cell size paired with a lower than normal hemoglobin content is called microcytic anemia and its cause is often iron deficiency. If anyone is more interested in a discussion of this see this very well written article: http://www.vet.uga.edu/VPP/clerk/mwoods/index.php Ask your vet if they think there is some kind of infection and do they plan on treating it or examining other causes. I think dropping to 70 from 80 is a relatively small change. Be consistent in having CBCs done so that you can make sure the decreases are not having a negative effect. I would keep in the back of your mind having another drug added to the cocktail. Decreasing prednisone is a great goal because of the negative side effects but there must be some other kind of immunosuppression for long enough a period of time to stabilize the immune system. my best patrice

Patrice NYS

Thank you so much for taking the time to answer my questions Patrice! The vet has mentioned the high WBC but she did not seem too concerned. I asked about tick disease, but since we don't really have them or Heartworm here she did not think that that was an issue. Kahlu's blood was also sent away and she said that would have been detected. I think I just have to be more on top of it and ask her lots of questions. With the things I have learned from you I can even ask specific questions. I will call tomorrow, maybe I can get some more answers and maybe she can consult with a specialist. She read up on Imuran and cyclosporin and seemed concerned about the same side effects as prednisone. But it seems everybody on this board has a second medication. Kahlu's diarrhea seems to be a bit better. Maybe he has an infection in his gut? Now would be a good time if they could talk!! Thank you so much again, good night, Brigitte

Brigitte BC Canada

They may want to add an antibiotic to his regimin if there is a chance of infection (sometimes even if they just want to prevent one in the beginning). Doxycycline works very well, especially if they suspect a tick borne or other blood parasite or blood bacteria, but they gave Tiggs doxy even though ticks weren't the problem for us- it's a longer course, I think at least 21 days. Some antibiotics also can help with diareha I think. Like I said, for Tiggs, the Aza/Imuran really has little to no side effects, where as the Pred nearly killed him in the high immunosuppressive doses. It's worth asking, they can stay on the Aza longer term than the Pred I believe, and it's not too expensive like Cyclo can be. I'm sure you'll get it all sorted out. Best, melissa and tiggs

melissa slc

This thread was discussed between 11/02/2009 and 12/02/2009

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