Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Hobbes' Evan's Syndrome

Hi, I've been reading along in some of the archives on this forum in the past while. Our <4 year old Airedale was diagnosed 6 weeks ago with thrombocytopenia and anemia and has been on a steady treatment of high dose Prednisone (100mg/day. He was 50 lbs when he 'crashed'). The following weeks have been a difficult recovery process although Hobbes has never been so bad off to absolutely require a blood transfusion. He did require IV's initially. The vets had strongly urged us to go for a transfusion when his HCT dropped to 19% however we have decided against this measure in our case, as we live very far away from any centres that could provide such support. Hobbes has had a typically slow but steady recovery for the first few weeks. Unfortunately, in the past 3 weeks he has steadily declined again. While he's not in the extreme zone yet, we will now be back to weekly blood work for monitoring. This coming Friday's blood work will determine whether Hobbes will be placed on Azathioprine as well. When Azathioprine was recommended initially (with the Prednisone, since his response was slow), I hesitated because of it's effects, and Hobbes had a very bad initial reaction to the pred. While his side effects are not life-threatening from it at this point, he has regular (several daily) incontinence spells and he has lost 10 lbs (down to 40 lbs today) of muscle, such that he is having great difficulty getting up from lying down now (let alone the stairs he can not walk up since the onset). These ill-effects seem to be progressing rapidly now, and it's dreadful to keep him on such a high dose of this drug, but he has never reached a level of stability that had the vets comfortable with decreasing the dose. To complicate matters, neither his red blood cells nor his platelets are regenerative, both occurring at below the normal levels. They both jumped quite high as an initial reaction to the Prednisone but it did not last very long. Today his circulating platelets are still in the normal range but have been dropping consistently as well. His anemia numbers have never made it into the normal range. His diet is raw. Apart from a UTI a few weeks ago, his scat and urine have been fine since antibiotic treatment (he's had 2 rounds of antibiotics due to secondary infections now) and I monitor all changes in it in case of internal problems popping up again. Hobbes' continues to have a lively Airedale spirit which seems to counter the devastation his body is going through. I'm looking for suggestions and thoughts around the Azathioprine start up...Anyone else who's poor pooch has been through such a change in numbers with their advice would be welcomed as well...I guess any advice would be. Also, we're going on a 'vacation' starting on Saturday and driving cross country to our sister's wedding. It's a 10 day trip and we're also not sure what to do about the medication changes leading into our travels (he will most definitely be coming with us). Would you just stick the current course until the trip is over and take chances, or take chances with introducing a new med before hitting the road. Either way we've already begun the process of getting vet information for on the road but really stuck on what to do in this situation. Any other vacation we would have cancelled, but it's her wedding and that's just not an option. Thanks for your support! Jenn

Jenn Campbell Ontario

Hello Jenn, I am so sorry for what you have to go through with Hobbes. I have a few suggestions. I live on Vancouver Island away from big teaching centers and clinics. About 6 weeks into my dogs treatment our vet was at a loss and needed some guidance. She recommended a specialist off the island or at least 3 hours away. This was not an option for me. I asked my vet to contact Dr. Dodds in California and consult with her. This was the best decision ever! We got excellent advice and my vet learned so much for the future. For medications I would think it would be better to add cyclosporin to the prednisone instead of azathioprene. Some dogs are even on all three. You will have side effects with all of these drugs. The question is not if Hobbes will have them, but how severe they will be. but these drugs will safe his life! Again Dr. Dodds will advise you what and how much to give. One of my strongest advices is always, please make sure your dog is on a stomach protectant!!! (Sucralfate or Carafate) This is VERY important and I can not stress it enough. As for transfusions, I don't think they are necessary before the HTC drops to 15. Now to the plan of your trip. I would certainly worry about that. Stress and heat are a big problem for these dogs. So now you have to out way what is the least stress.... I am pretty sure taking Hobbes along will be better. I took my dog on a 3 week trip when he was 6 months into the disease. I was very careful to keep him cool. I got a cooling jacket (we went to Nevada in the summer) have lots of water with you, a wet towel to drape over him. I would not switch any medications during that time and try and keep him as stress free as possible. Please post his weight, medications and dosage Hobbes is on, I am sure some people here will have some advice. Have a look at Joanne Dicksons website: http://www.cloudnet.com/~jdickson/index.html There is a lot about AIHA/ITP and Evans syndrome. If you go to the success stories, you will find the stories of dogs who have fought and won the battle! I know there are some with Evans syndrome, but I don't the names know off hand. Please get in touch with Dr. Dodds at hemopet @ hotmail .com (remove spaces) as soon as possible, You will not regret it! Best wishes, Brigitte & the poodle boys

Brigitte BC

Dear Jenn, I am so sorry to hear of Hobbes Evans Syndrome. My dog, Tootsie, is the December 2010 success story and you can read about her at http://www.cloudnet.com/~jdickson/archives25.htm. Tootsie was diagnosed with Evans Syndrome and started on prednisone and Azathioprine at the time of diagnosis. Tootsie is still taking 3/4 of a tablet of Azathioprine once a week. She has not had any noticeable side effects from this since the initial severe symptoms at the beginning of her illness which, I think, were entirely from the prednisone. She is being weaned from the meds very slowly. She is very healthy now and her blood tests have been coming back great. Her medicine has been reduced about every two months and she will be off of it for good soon. You and Hobbes will be in our prayers. Please let us know how he is doing. Barb and Tootsie

Barb Ohio

I am very sorry to that Hobbes has been diagnosed with AIHA. My golden Ginger did just fine with the azathioprine and she also was on cyclosporine and pred. I personally think 100 mg of pred is a lot for a 40 lb dog. It is usually 1 mg per pound so Ginger weighted 80lbs and was on 80mgs a day. Sometime a higher dosage will be given in the beginning but not that high of a dosage for too long. Is Hobbes on pepcid or a stomach protectant? We were on our way on a 12 hour road trip for a weeks vacation to Maine when are vet called with the diagnosis of AIHA, so glad we had Ginger with us and we began her pred there, she just needed extra bathroom stops and had a few potty breaks during the night, but we pretty much just left her rest in the cabin we stayed in and checked on her frequently and found the name and number of a few vets nearby just in case. Sending prayers for you boy Hobbes Cheryl & Ginger

Cheryl & Ginger Pinevile PA

Hi JEan, Sorry to hear about Hobbes condition. I have limited experience, but from what I can see, most vets are using 2 mg/pound per day split into two doses. This is despite what I have read that 1 mg/pound/day should be sufficient. When I see a good response in the first 2 - 3 weeks followed by a decline, I suspect too high prednisone (there are other possibilities too I am certain). How dogs react to high dose prednisone varies, but when Dylan started, her side effects were very pronounced. I pushed my vet on the dose and we dropped it from 100 mg/day to 80 mg/day (she was 48 pounds) right away. Her PCV bounced back to 39 in 2 weeks. I saw a small decline in PCV and hemoglobin and reticulocytes over the next 4 weeks on high dose prednisone, even at 50 mg/day and 40 mg/day. With Dylan, her PCV was strong, so I lowered prednisone pretty aggressively, but was sure after each lowered dose, that she was relativley stable (PCV decline was very solow and went from 39 to 35). Check out the photos and video on Dylan's thread, they will show how bad she got (diagnosed March 19th, photos start April 17th, when she was already immobile (only mildly anemic) and how I handled her paralysis from prednisone to help her pee, and her recovery). Also there is a big difference in her when she was anemic versus immobile from prednisone. It is not unreasonable to think that too much prednisone is also inhibiting red blood cell production. I did get a fair bit of resisteance to this idea (although some very much support this idea too), but I am convinced that in Dylan's case she was on too high a dose and in the end whatever triggered it was gone from her body. I was never certain of this until recently though. It may also be something else, so please read all suggestions. Prednisone will cause severe muscle loss, but when it ocuurs over 3 weeks, as it did with Dylan, I was concerned, as was my vet. This led her to support reducing prednisone. They do recover once it is reduced though. Dylan is fully mobile and putting on muscle now that she is off prednisone. One other important fact was that when we went to 50 and lower, we did not see spherocytes (although we did see other anomolies from prednisone). Please check the other recent threas, as there are things there that will help you too. Maybe run this idea past your vet. Wishing you the very best in your fight, Richard and Dylan

Richard Burnaby

Sorry "Jenn," don't know what happend with my head or fingers there. Richard

Richard Burnaby

Hi Jenn: I was just wondering if you had considered having Guelph University watch and care for Hobbes while you travel. They are the elite teaching hospital in Canada and happen to be in Ontario. They would in all probability find space for him. I know that my uncles dog had an emergency situation and the dog was sent down from Huntsville to Guelph for their specialized care. That would take the stress off each of you and Hobbes for a little while. I can't think of a better place for treatment if it happens to be within a reasonable commute or along your journey.

Elaine Ottawa

Hi all, thanks for your input. It's so very helpful to know there are others with experience and knowledge of this condition. Hobbes' primary vet thankfully has a good deal of experience with blood disorders and keeps himself up to date with current research so I am confident in his decisions and explanations for medication choices and supports. He will be connecting us with vets along the way should we need to make a stop anywhere. I appreciate the suggestion of going to Guelph however Hobbes endures a lot of stress when he is kenneled away from us. After several great occasions at the kennel, Hobbes would fall quite ill (leg limpness; tail paralysis; pneumonia; depression) within a few days of returning home each time. We eventually made the decision to only leave him with my parents when we go away. On a side note, Guelph is also a 14 hour round trip, which is the same distance we'll be going one way out east. We've tested out Hobbes for travel on 2 occasions now, both were weekend trips and he was in better spirits than he has been here at home. We'll just have to be sure to keep him quiet so that it's not too much excitement. We've decided now that we can cut the trip short by close to a week, if he is worse off come Friday. That will give us more time to stay home with him while beginning a new medication, should there be a poor reaction. I'm curious about the Cyclosporine idea. Why would that be chosen prior to trying Azathioprine? As I understand it, there are more drastic and numerous side effects associated with that medication? Does it act differently on the blood problems? I've read some research trials now and Prednisone is *sometimes* used at doses of 3x the body weight. It's hard to watch while you poison your dog but knowing full well that the alternative at the moment is worse. Today I bought Hobbes a belly wrap to catch the accidental pees. It caught a dribble in 5 minutes. I'm also going to play around with a sling device to help with his hind legs, should we come to rely on this. He's also slept a lot since yesterday, which is a sure sign that his numbers are down but the weather has also been wet, and he always sleeps on days like this. The rest of the week is calling for sunshine - so I'm hoping his mood picks up with it. Hobbes is on Pepcid, 2 bid, an hour before meals and pred. His stomach has been managing quite well on this. His bm and urine continue to be fine in the past 3 weeks and I keep a very close eye on these for any changes or blood. He had to be on Sucralfate (6 days) initially as he was bleeding out quite badly, but so far that seems to be resolved and I'm not interested in putting more drugs into Hobbes' body than absolutely necessary...and the vets are supporting this decision. If we do end up going on another medication come Friday however, I will be asking for another supply of Sucralfate to mitigate the reaction from introducing it. I've read/looked at the links you've provided me - thank you so much! I was able to find 7 dogs with Evan's Syndrome and each one, like all I'm sure, are quite unique in their experiences. They've helped me to think about how we might handle different ups and downs through this experience.

Jenn Ontario

Jenn, I am just catching up with your story about Hobbes. I am sorry to hear about this. My dog had a similar condition, non-regenerative but also not making white blood cells (neutropenia). So thus he had bicytopenia. Non-regenerative cases are different than AIHA and more difficult to treat. The blood cells are not destroyed usually in circulation, so there isn't a fast drop in the number of red blood cells in the blood. However, our RBC's age and are replaced at around 120 days. So there is a gradual loss over time as they are not replaced. One expert Dr. Jean Dodds, feels from her experience, that in many canine cases it is caused by autoimmune destruction of the precursor cells in the bone marrow. All three lines of cells; white, red and platelets, are made from the same precursor cells. If you destroy them then they cannot mature into these three lines. Some dogs only have a loss in one line while others may have a loss in two lines, bicytopenia (Evan's) and some very unlucky dogs have losses in all three lines, pancytopenia. The condition seems dire and unresolvable, but as my dog proved, there is great hope. It took much longer to help him but he did survive and had a good three years after until he passed at 12. I want you to know this was very very hard. It took round the clock care at home in our case. My husband was right there with me and there was no disagreement from my vet about our continuing to support Chance and supplementing with transfusions as required. In addition my vet was very pleased to work closely with Dr. Jean Dodds on a consultation basis. So 90% of the treatment came from my local vet. Nursing care was my responsibility. Keeping Chance close to home and his environment stress free was essential in his recovery. You asked about cyclosporine. This is a drug that was originally developed for humans who had undergone organ transplants. Because their immune system would attack the "not self" organ, these patients were put on high dose prednisone to suppress the immune system. However, the side effects of long term use of pred are very serious and these patients became very ill from that. So researchers developed a fungus into a special immunosuppressive drug called cyclosporine. The beauty of this drug is that it does not suppress all elements of the immune system, but seems to target just the Killer T-cells. These are white blood cells that seem to go "haywire" in autoimmune conditions. This drug eventually went on to become a standard human medication and saved many lives. About 10 years ago veterinary researchers began to test cyclosporine for use in dogs. The eventual application is a drug called Atopica that is used in canine allergies (atophy) and it has been enormously successful. Its use in autoimmune conditions has not been studied but its use off label in veterinary care is very common. Dr. Dodds began using human cyclosporine for canine autoimmune blood conditions many years ago and was very successful. Why do we mix immunosuppressants? The first drug that is always used is high dose prednisone. This is essential in the early days. However, the side effects at long term are very hard on the dog. Adding in a drug like cyclo and/or aza adds in targeted immunosuppression with the goal of beginning the decrease of prednisone and thus changing the main suppressive drug to cyclo (or azo). This reduces the pred side effects a great deal and allows for excellent continued suppression long term. Cyclosporine is, compared to prednisone, a very safe drug for dogs. I have read the results of the testing for Atopica carefully and they indicate that for most dogs it is safe with very few side effects and that any side effects generally go away quickly once the drug is removed. The tests used very very high dosages that would not be applied in actual treatments. Side effects in general at lower doses are gastrointestinal, vomiting, diarrhea etc. and can diminish after a few days. Some unlucky dogs cannot tolerate it however because of this and must discontinue. There are some other cutaneous side effects at high dose long term use that I have seen some owners complain of here. They are unsightly but not life threatening. Because Hobbes *may* be on immunosuppressive for a long time he needs to have another primary drug to do the job. You cannot continue the prednisone at the high doses for the possible months this might take. I learned this too well from my experience with Chance. I would recommend you do not eliminate the sucralfate. This is essential in preventing unknown stomach ulcers. It is really just a paste that covers the tissue to protect and heal it. For that reason it needs to be given away from drugs and food because it will interfere with absorption. I promised myself that I would always caution owners about this after one of the owner's dogs here on this forum died on the operating table after eating multiple socks. The dog had very bad ulcers and was eating socks in an attempt to stop the pain. There is a good reason for every drug/supplement you give. That is why Chance had round the clock administration of meds and supplements. He is peeing because of the prednisone. The condition that it creates is called Iatrogenic Cushings Disease. Or it is caused by administration of prednisone and will resolve when the drug is removed. I love this website's explanation of this condition. You will find Iatrogenic on this page: http://www.kateconnick.com/library/cushingsdisease.html my best patrice

Patrice NYS

Thanks for all the information everyone - I really do appreciate it. There is so much to absorb and at times it is overwhelming yet there is much reassurance, and that helps. One thing I'm still not clear on is what constitutes "long term use" of Prednisone? What do people mean by long term? I mean, 3 weeks is a long time on antibiotics but 20 years is a long time on a Salbutamol inhaler. What is too long on high dose Prednisone (eg. 2 mg/lb). Hobbes' vet, while he is concerned and empathetic towards the side effects Hobbes is experiencing from the Prednisone, has wanted to give enough time to allow the Prednisone and Hobbes' system to work together - there was an initial, albeit delayed, good response on this medication after all. On that note, we're also dealing with a repeat offender: a bladder infection. The symptoms began yesterday morning, after about 5 days off the 2nd course of antibiotics. He was peeing more, it was sputtery, and he was drinking more water than usual (yes, even for a pred head). He had a urinalysis completed this morning - there are no stones (which was the primary concern) but there are bacteria - and is now on Zeniquin for a 3 week period. Our regular vet was not in today and we have blood work scheduled with him for tomorrow so we will discuss this issue more at that time. I guess the Prednisone is the drug of choice because it's the most effective in the majority of cases then? Am I correct to assume that the other drugs he may have to take will not be as hard on his system as this one? thanks again!

Jenn Ontario

High dosage prednisone use for immunosuppresion will begin to show side effects immediately. Long term use over probably 14 days up to 3-4 months can show significantly more side effects that are mostly reversible once the drug is removed. Up to one year and over, there are some non-reversible side effects. Low dose prednisone treatments can be tolerated more easily for long term and some dogs (and humans) are prescribed this for many conditions. The difference lies in how much prednisone given orally replaces or exceeds the amount of cortisol the adrenal glands would produce for themselves. Anything more than a normal amount in the body will result in systemic changes. Larger doses behave more like an adrenal tumor. The point here is that if the prednisone is not working after 3-4-5 weeks, then there must be a reason and another drug or more testing must be done. It is a great first defender but a poor long term solution. my best patrice

Patrice NYS

that was very helpful Patrice - thanks so much! Now I have a better sense in my head of where Hobbes' stands in terms of his dosage. I knew it was quite high but wasn't sure about how long...He definitely had immediate side effects from it - lost all his muscle mass (and muscle mass was all he had) and I know that's why he's lost so much weight. Today he weighed in at 40 lbs and this number seems to be more consistent now (still a slight decrease but not the whopping amount he lost a few weeks ago). His blood work came back this morning pretty positive - it hasn't gone up but the drop has stopped so he's steadied between Monday and Today's checks. I contribute this change to the antibiotics for the bladder infection. Hobbes has made improvements every time he's gone on antibiotics and then dropped after a few days of being off them. The difference now I think is I knew what to look for and got him back in right away, before his WBC went completely wacky. We've been given the contact information for a good vet where we'll be in New Brunswick and the teaching hospital in Charlottetown, PEI, should anything go amiss. I don't think there will be any problems now that Hobbes is on the antibiotics but it's good to have the information just in case. Since his numbers are leveling out, we're not going to start other medications at this time. He might make improvements with the infection remedied while we're away. If, despite this extra treatment, his blood work hasn't changed in 2 weeks' time, obviously, we'll need to revisit this. On a side note, behaviourally, Hobbes has had more energy in the past 2 days then since this horrid commotion had started 7 weeks ago. He actually pulled a toy out of his toy bin and shook it around for a few minutes! The sheer delight at such moments melts our hearts here! His terrier energy has been MIA until now, so I guess it'll be an extra eye out for him to ensure he doesn't get carried away with what his body can handle. Still, heart-warmed is how I'm feeling today! Take care for now, and I hope all is well with good news for everyone else too.

Jenn Ontario

Hi Jenn, I love to hear that Hobbes wants to play. That is a great sign. I to feel that every little thing is so special. Every moment they gain something back is a great moment (I was in tears for half an hour when Dylan stood for the first time after being immobile for over a month) and it can be the tiniest of things that spark hope and give us those clues they are headed in the right direction. Such an important part of the treatment is seeing them and knowing what they mean. I too love my terriers. I know you understand the joy I feel when Dylan stretches her back legs. She had no muscle and stopped that months ago and now she does it on a regular basis again amongst many other wonderful things she has not done since diagnosed with AIHA. Unfortunately the treatment will also take some toll on these wonderful things you like to see in Hobbes, but your hard work and caring ways are sure to help minimize it and bring every bit of Hobbes playful charactor back for you to enjoy together. I was fortunate that whatever triggered AIHA in Dylan allowed me to remove prednisone without immunosuppressants, but every case is unique and more often than not, longer term treatment is required. I am glad Patrice was able to explain things for you. I am sure everyone who reads it will benefit. Knowing what they do and why to use them is so imnportant in deciding what to do for treatment. Please keep us updated, we will be hoping and praying for more good news. Richard

Richard Burnaby

Jenn, That is so great that Hobbes is maintaining and wants to play! Penny

Penny Lytle Creek Calif

This thread was discussed between 11/07/2011 and 15/07/2011

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