Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - For Richard, ? abut relapse

I wanted to respond to your question on the other thread abuot relapse. I have read a lot here and other articles that say removing prednisone too soon can cause a relapse. I wish I had bookmarked them for future use. Wylie had a relapse 7 months after initial diagnosis, I attributed to either 2 things, her heartworm med I gave her the prior week or the fast removal of pred my vet did. Wylie had a very good response to pred and other numbers shot up to 39 fairly fast so his thought she is normal lets start taking her down and off. So she was basicly off in a matter of 2 1/ months. The next tme he said lets go much slower, so this was over 7 months and that was almost 3 years ago and she has been fine since. Laurie

Laurie Ca

Hi Laurie, So have you given the same heartworm med in the last three years? Richard

Richard Burnaby

Hi again, Do you have any idea what the first trigger was? Richard

Richard Burnaby

Hi Richard, yes she has been on the same heartworm since interceptor. We have it bad here so no getting around it. My thought of trigger was possibly a bee sting since it was in the spring and in area she likes to hang was full of them. We had been watching her liver values closely for several months as the previous sept she was diagnosed with leptosporosis and jaundice in early april and mid april diagnose dwith AIHA. She did have a small growth on her spleen that turned out to be benign, and the vet said it could have been sporadicly bleeding out to cause AIHA. One thing I am now curious about is if she was put on antibiotics for her jaundice as a certain type can trigger AIHA too. After diagnosis I kept meticlouly spreadsheet of all of her bloodwork. first onset her HCT never got above 41, this in normal range and because of no spleen should be lower, after relapse andn being on pred longer, it has been 47-50. Laurie

Laurie CA

Hi Laurie, One thing I did not say and should have though is Congratulations on Wylie being AIHA free. No matter how you get there, I am sure that is a great relief. I am not sure I could relax though, as this disease seems to always be lurking about. So when I listen to your story and your thoughts on the situation, I keep having thoughts of other possibilities of what was going on and how I might have handled it. I am going to write more on the alternative scenarios/hypotheses once I get more time and understand it a bit better. For the moment though, it seems like the hematocrit never getting over 41 was assumed to be free and clear and maybe was not? This is still something I am watching for in Dylan. I truly do expect it to continue to go up and if not I will be looking for answers. I do not expect her to sit at the low end of normal, for any other reason really. Since the hematocrit is now 47-50, I would have thought after 5 months off prednisone (approximately, from stopping it, to the relapse), I would have expected at least a slow climb, almost solely because I now know it could have been much higher than 41. I am assuming she still has no spleen? ;-) How long after the relapse/end of prednisone did it take to get to those higher numbers, say 45 and up? So they removed the growth and the spleen after the initial attack right away? Or some time later? Also, what sort of timeline did you have for prednisone withdrawal then? From say, 2 1/2 months to the end? Also, I need to know her weight? Anyways, I hope you have the time to continue this, as it is helpful to my understanding of what to expect and prepare for. It does not change my feelings about getting Dylan off prednisone quickly and I will explain my thoughts later for sure. Thanks for helping, Richard and Dylan

Richard Burnaby

Here is a synopsis, we were very lucky as I said we had been monitoring her liver values so we caught the AIHA before a big crash so over over a 2 week period we saw he go from 40 to 35 to 30 and then got the definnative AIHA diagnosies. She is 53# and was started on 30 pred a day on 4/19 by 4/29 she was up to 38 4/29 decision made to remove spleen so pred was reduced to a fastrack since they did not want her on it for sugury. that was done on 5/7, she was back on pred her HCT was back down to 34 5/19 vet she was 40 vet reduced started the reduction in her pred, last one was on 6/29 (research shows you need to be at a normal level for several weeks before a reduction) July, August Sept she plugged along at 38-40 Nov 1 she became listless, I looked at her gums and knew immediately a relapse, her HCT was down to 27. This time she was put on 40 mg of pred a day and sorry it was five months not 7 she was on it. By December 6 she was up to 47 and has been in that range ever since. Laurie

Laurie CA

Regarding Dylan, at this time; I do not know and I am in no way certain she is free and clear of AIHA. I still watch her like a hawk. There are still signs in her that she is not done with her prednisone recovery (issues in her skin that are certainly healing, but I am not certain there are no new issues yet). These signs, might be something else, although I am optemistic they are all clearing up. Althouuh she is doing very, very well, her hematocrit rose to 42, her spirit and energy along with her strength are growing for sure, and there are no spherocytes, or other signs in her blood at least, I am in no way certain, nor assuming we are done. Praying we are maybe :-) Happy to have her happy every day, Richard and Dylan

Richard Burnaby

Hi, Dylan's hematocrit remained strong from 2 weeks post AIHA attack (instant attack too, no 2 weeks) until today. She had a minor slow steady reduction which contiuned until prednisone was reduced. Everyone here (all 3 vets and myself) believes this was not AIHA induced and due to high dose prednisone, mostly due to the slow and steady nature, paralleling her time on prednisone and the lack of spherocytes. So that was 3 months with low normal hematocrit before removing prednisone completely and at least 2 months (and more if you consider the residual effects probably) at an immunosuppressive dose. Just from your description of your timeline compared to Dylan's, I do know Dylan was very different even though initially I thought they were similar. Wylie's dose of prednisone was nowhere near as high at any point as Dylans (48lbs and 100 mg per day) and her pcv and status was never stable. Dylan was very stable. From the way you describe Wylie's timeline, at no point do I feel you are certain of what you were seeing, that is, that Wylie was AIHA free. The fact that Wylie has acheived a number of 50 since the relapse and did not come close to acheiving it July through September, before the relapse, supports this hypothesis. If Dylan does not continue to climb, I will certainly become concerned about why that is. But unlike Wylie, Dylan has not plugged along. Her pcv rose to 39 right away, slowly was suppressed until prednisone was low enough and it has climbed to 42 since. If it goes down, or stays the same, this to me will be a sign we are not done. If it continues to climb, I will be more certain of her situation. Will there always be some doubt? Yes, I do think so! Can she suffer another attack, even if she is completely free and clear? Absolutely! Her immune system is as screwed up as it was before the last time it attacked her. Whatever trigggered it even if gone, could appear again and cause AIHA to happen again, or maybe her screwed up immune system does not like somtheing else she injests, or is treated with... I am not trying to be pessimistic, just trying to know the possibilities and be prepared. Thanks again, this is very helpful, Richard and Dylan

Richard Burnaby

Hi Laurie, From what I know about triggers, they require 2 things; a screwed up immune system (genetic and early developmental issues?) and a toxic trigger (what is toxic, may not even normally be toxic?). Whatever the trigger is; in a normal dog with a normal immune system, it does not produce any immune attack on the body. Where the attack occurs does matter. It certainly impacts the profile of anemia and cell destruction you see. In Dylan, mature cells were killed quickly. I don’t believe immature cells were attacked partially due to her quick recovery and even if they were, the machinery to produce red blood cells was definitely not under attack. On the other hand, prednisone suppressed the attack quickly as well, so again, I am pretty much guessing. In this case though, if I reduced prednisone while the toxin was still present in Dylan, I probably should have seen a decline in pcv in some way, which would continue as prednisone was reduced further, or maybe accelerate even, especially after immune suppression was no longer possible. I really don’t think one would see a steady climb throughout and after prednisone was stopped. Still guessing though :-( Waiting to see where her pcv and blood work goes over the longer termfor that decision. The problem still is that, no matter what I do, Dylan has a screwed up immune system that CAN attack itself under the right (wrong?) conditions. That itself creates a lifelong need to watch closely I would think? And a lifelong possibility of relapse with either the same trigger again, or a new trigger, unfortunately. My fingers and toes seem to be permanently crossed now ;-) Richard and Dylan

Richard Burnaby

Richard, your thoughts are intresting on a screwed up immune system, Wylies was screwed up big time since her diagnosis of Lepto being on antibiotics 2 or 3 times at that time with Lepto, and then you have to give doxycylene for at at least 8 weeks which she in Sept so was this a factor? I had not though of that until now. Just that was AIHA a pro-curser to the lepto diagnosis and she also in the last 2 years about 2 bouts with thromboceptemia. Another interesting factor her as soon as she on pred both times her HCT rose fast almost immediately. Laurie

Laurie CA

This thread was discussed between 24/07/2011 and 26/07/2011

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