Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Holly's bloodwork Nov 12

Got Holly's bloodwork back today, and so depressed! We really thought she was on a good road but looks like we are going to have to increase her prednisone back up again. Her Hematocrit was okay at 39.6 down from 4l.4 four weeks ago. But her reticulocyte count is back up again to 1.5 and now her white blood count is low at 3.1, 4 weeks ago is was fine at 5.0. We have been going 4 weeks in between each reduction and currently are at 2.5 mg every third day and the azathioprine is still every day 2mg. I really thought from what her Internist in Atlanta told us that the azathioprine would be a good theurapedic drug to maintain her levels so we could decrease the prednisone, but it seems that it is not really helping to maintain. Only the prednisone is doing that. And now I don't know what to think with her WBC being low. Also her Lymphocytes are low at 620 which not sure what that means. Has anyone experienced this with the WBC?? The frustrating part is that I found out this afternoon that our regular vet is out of town until next Monday and the internist is not in again until Thursday, at which time I will try and contact her again. I called and left several messages for her today. This disease is really a frustrating disease! It seems to consume your life with worry for our loved furry babies. We know in our heart that Holly is much better then she was 8 months ago, but it is like a friend said to me today, like cancer a person might seem good but it can take a hold hard and fast at any time. Thanks for listening, Linda

Linda Sapphire

Linda, Try to hold on to the positives. Think of how far Holly has come. Some dogs do have to stay on a low dose of Pred for life and go on to have a normal doggy life. Did your Vet not make any recommendations before he left town? Hang in there and know we all listen. Penny

Penny Lytle Creek Calif

Linda, sorry to hear your news. Lately I have been thinking the same thing about cancer patients - that they may look so healthy and yet things could change so dramatically at any time. I think my family thinks I'm being pessimistic when I say that Duck is holding his own for now. They don't understand my guardedness about Duck's condition because they are seeing a dog that looks and acts great. But one of the horrible things about this disease is that there are no absolute fixes and no guarantees. Hang in there and like Penny said, try to remember the positives. I hope the internist gets back to you first thing tomorrow with some good advice. Please keep us posted and know that my thoughts are with you. deb and Duck

Debbie BC Canada

Linda, our thoughts are with you and Holly. For Holly to have made it this far, you and she must be terrific fighters. The second worst part about this disease (the first worst being our dogs feeling so bad for so long) is knowing that there are likely to be set-backs. We can celebrate the positives (Shadow, who was diagnosed on Oct. 19, had her first PCV increase, unaided by a transfusion, on Monday. I was happier than if she'd won both multi-state lotteries!) but it's always lurking in the back of our minds that the next CBC might not have the results we want. Shadow and I will keep our pads and fingers crossed, respectively, and say a bunch of prayers that Holly's low WBC is a temporary set-back, brought on by something that's easily fixed, unrelated to AIHA. (We who live with AIHA kids have to dream big or we couldn't ride this roller coaster.) And, I completely agree with you: AIHA consumes our lives. I can remember every one of Shadow's PCV counts (in chronological order and the dates the blood draws were taken); I can't remember what I had for breakfast (or if I ate breakfast) an hour ago. No one who hasn't lived with a dog who's battling AIHA knows what it's like: that's why this forum is so valuable. And that's why it needs to stay open and accessible to everyone, however angry, hurt, sad or joyful they might be feeling, who lives with an AIHA friend. Sorry for being so wordy and opinionated. Shadow and I ARE keeping our pads and fingers crossed, and saying prayers for you and Holly! Sandy & Shadow

Sandy Utah

Linda, Completely understand your feelings about this disease! With respect to the WBC, has the specialist or your vet talked to you about possibly having to reduce the Azathioprine dose? One of the stated side effects of the drug is bone marrow suppression, which may be why you are seeing the dip in WBC. We encountered this with Murray after he had been on it 6 weeks (he was also on a moderate dose of Pred at the time and had just started cyclosporin since we weren't seeing any regeneration). With him, we saw a dip in the WBC below normal (which the internist we were seeing at the time dismissed) and then a couple weeks later, he crashed with a high fever and had become septic - his WBC continued to drop dangerously low and the (new) internist pulled him off all the IMHA drugs in order to give his marrow a chance to respond and fight the infection - which, happily, he did. I have read other cases though where the reaction was not as extreme and they either reduced the dose or went to an EOD dose of the immuno-supressant drug. I wish the initial internist had taken the low WBC a bit more seriously (that's why we switched) - we might have spared him a lot of pain. I hope this helps - good luck with Holly. We all know what a complex puzzle you are trying to solve. Bonnie

Bonnie Chicago

Hi Linda, I just wanted to let you know that Tipsi and I are keeping you and Holly in our thoughts prayers. I realize that it's so frustrating to get news like you received, but you just have to keep thinking positive thoughts. WE all know that this disease is like taking a long roller coaster ride. There will always be ups and downs. You are doing everything possible to keep Holly healthy and thats all you can do really. As Bonnie mentioned in the previous post, you may want to speak with your doctor about reducing Holly's azathiorpine dose. It could potentially be causing bone marrow suppression. Just a thought really. Please keep us all updated as usual! I'll be thinking of you. Layla & Tipsi

Layla Raleigh

those are great #'s... a 39.6 down from a 41 could simply be due to fluxuation or a different blood spin method or spinner. sway's WBC goes all over the map and is usually different on every single panel we get back. good luck tho of course!

josh california

Thank you all for your kind words, and please know that it helps so very much to know we have friends out there to talk to about this. It means so much!!! This is a very difficult time for my husband and me, as he lost his Mom last year the day after Thanksgiving to a long battle with cancer. And my Mom is gone now 2 1/2 years to cancer and we both watched them die. My Mom went very quickly, had surgery in Feb and died in April, to know that she was walking around with all that cancer in side of her for such a long time as it grew was heartbreaking in the end. I know that Holly has made such big improvements and we are so proud of her right now, so it just rips me apart to know that we are taking steps backwards now. But knowing this disease like I do now, I know this is for sure a part of it. Roller Coaster all the way. My first thoughts on the WBC was the Azathioprine, but she actually started on it August 7, so we are into our 3rd month on it, and because last blood draw 4 weeks ago she was at a 5 before that was 4.2, so I thought she had overcome it with the possible bone marrow suppression. Bonnie, how low did Murray's WBC go?? and when you say he crashed and became septic, can you tell me exactly what happened, so I know what to look for if that should happen to Holly. I would so appreciate it. Josh, we are not concerned in the little dip in Holly's PCV as this has happened many times up and down by a few degrees. When you say Sway's WBC are all over the map, do they go below normal and back out again? Our local vet was not in at all yesterday, so the girls faxed the results to me, so he has not seen the results yet, but I am so hoping to talk to the internist in Atlanta about it tomorrow. Thanks again to all for your kind words and Holly sends her love to all of your furry babies. Linda

Linda Sapphire

Hi Linda, Murray had been on Azathioprine longer than is "typically" (whatever that means) seen when there is bone marrow suppression - he wasn't on it as long as Holly has been but we did think he was "out of the woods" with respect to that risk. His WBC was 9.6 on May 24th and dropped to 4.2 on May 30th (he had only started a low dose of Cyclosporin two days earlier on the 28th). The internist we were seeing at the time(he was board certified and was highly recommended for treating IMHA by several vets) was not at all concerned about the low WBC and told us to continue on the 3 meds (Pred, Imuran, Cyclo). His next labs were June 6th and his WBC was at 4.7 (which was still low for our lab). He crashed the evening of the 6th a couple hours after we got home from the vet. He had diarrhea, multiple bouts of vomiting, and when he would lay down he would shake (I learned the next morning that was a sign of fever). We watched him through the night thinking this was "just" a reaction to the Cyclosporin b/c they were having us build him up to a higher dose. But, at 5:30 the next morning, when he wouldn't take his Pepcid hidden in a meatball of canned food, we went to the ER (by coincidence we had an appointment with a new internist there later that same day). When we got there we had to carry him in and his temp was 104.4 - his WBC went as low as 1.3 over the next four days and the internist was very concerned we would lose him b/c his body didn't even have a "minimum" level of support to allow the antibiotics to fight the infection (thus why she stopped all the IMHA drugs, keeping him only on a base dose of Pred). On the 5th day, he was clinically better and his WBC bounced up to 2.3 so she said we could take him home and "see what happens" (of course there was an army of antibiotics involved). About 10 days after coming off the IMHA drugs, his WBC was back to 10.4. Sorry for the lengthy message but I hope the detail helps and I hope you aren't facing a similar situation with Holly - please keep us posted. Bonnie

Bonnie Chicago

Bonnie, No not lengthy at all! I so appreciate the information in fact I printed up to be ready for Dr tomorrow. I am so sorry because really does sound like Murray crashed hard. In Holly's case her WBC on 8-21 was 8.9 and we started the Azathioprine on 8-7. on 9-5 it dropped to 4.5, 9-11 was 4.4, 9-25 was 4.2 and then on 10-16 went up to 5.0, so we thought she was okay, and now 3.1 (Antech says normal is 4-15.5) So happy to have this information to discuss with the internist, so this way it looks like I know what I am talking about, which is why I love this board so and all of you on it! Linda

Linda Sapphire

I just wanted to let you know, well I did not speak to the Internist in Atlanta, but I did fax another letter to her this morning and she responded back via my vet up here in NC and they sent to me. I guess she does this because she is basically not being paid anymore other then when Holly was in the hospital, so she advises my vet up here on next steps. Bonnie, I have to say that she said the exact same thing your internist said " I am not concerned about the white count at this time as the neutrophil count is still normal" Holly's is 2232 range is (2060-10600). She also said that the increase in the reticulocytes is of concern. So she wants us to start Holly back up at 5mg of prednisone once daily for 2 weeks and then recheck reticulocyte count. She says we might have to taper her more slowy off of the prednisone and to continue with the azathiprine as before every day. So here we go again, 1 stepp forward and 3 stepps backwards! UGH! We were actually down to 2.5mg prednisone every third day and Holly's PCV is still good, but she is concerned only at this point about the retic because that means destruction is still going on and in Holly's case her PCV was a very gradual drop in the beginning and her body adjusted to that, so I guess that is what she is afraid of. I was really depressed this morning but really expected it. The funny part is that she said more of a gradual reduction, so the way I see it Holly is going to be on this prednisone for a long time. Each of our tapers were very slow 4 weeks at a time, started with 10mg, then 7.5mg, then 5mg, then 2.5mg and then to EOD. So I am now wondering how much more gradual can it be. Sorry to go on so long, but sometimes it just helps to talk about it or I should say type about it. Linda

Linda Sapphire

We had the same bad news with Daisy yesterday...she seemed to be doing so much better I was expecting her PCV to be much improved. The specialist wasn't in but she did call and told me her PCV is 30 slightly up from 28.2 two months ago. She wants to keep her where she is on meds with Prednisone 20mg/twice a day and Immuran 50 mg once.(75 lbs). I don't have the complete report to see how her reticulocytes, liver enzymes, etc. have responded. WEe are four months into this and I guess we just have to be patient.

Ron B San Mateo

Linda, Hang in there with Holly-she really has done well! I don't really have any idea what could be going on, but I hope your vets can figure something out. I do know that we've been going 6-8 weeks between decreases for Slinky lately. I'm more comfortable with that due to the other things going on here, but I don't know that that is our vet's motivation vs. playing things safe. We held at 2.5 every day for 8 weeks and are now holding at 2.5 eod for another 3-4 weeks (her pcv was 49 this last time, highest yet). Slink is on 2.5 pred eod and Imuran eod. Bonnie has the most experience with the down side of Imuran, so definitely pay attention to Murray's experiences. I hope that's not what's going on for Holly.

Stephanie Chicago

Stephanie, Thanks. Right now just watching her very closely because of the WBC and hoping and praying that this was just a fluke, but at least I know the signs to look for. Other then her being once again starved out of her mind so far so good. Once we have the blood work done on Dec 3, I guess the internist in Atlanta will tell us again what the next step will be and we might just have to do this very slow decrease like you are doing with Slinky. That is great for Slinky 49 WOW! One time months ago, one of Holly's PCV readings was 50.3, but again I think it was a mistake. Linda

Linda Sapphire

Linda, Steph, maybe our doxies are a breed that has special sensitivity to the pred?? I too am using the safe route w/Choe as he has been on the 3 mg doseage of pred for about a month. Decreasing has sent him below the remission range. Perhaps 8 weeks does make sense. His hct floats around as well. As long as he stays above 40 I am happy. However, since he is now gong on 15 months of being diagnosed would really like to see his own system kick in. Jan

jan philly

Linda wrote: >Also her Lymphocytes are low at 620 which not sure what >that means. Has anyone experienced this with the WBC?? Linda, While we are all suppressing our dog's immune system, we are really, in essense, trying to suppress the lymphocyte t and b cells. They are responsible for responding to the alerts of the immune system and destroying invaders. They see the "foreign" markers on the blood cells and attack them thinking that these are not "self." Quieting them down is very important. As others have mentioned... some of the immunosuppressive drugs can suppress the bone marrow. If the neutrophil count continues to be normal then your vet is correct, it is all right. They comprise the largest percentage of white blood cells types out of the total. If you are seeing gross increases in reticulocytes and a decline in pcv, it might indeed indicate destruction. A moderate increase in reticulocytes and a fairly steady pcv that is a little on the low normal side could be just a normal reaction by the body to fill a need for more blood cells. Only a diagnostian can tell you for sure. The normal range of reticulocytes is .5 to 1%, but that is in a dog or human that has a normal pcv of 37%-55%. I would not consider, *for myself*, a number of 1.5% extraordinary and something to worry about if the pcv was in the low normal range. I would retest in one week just the pcv and see if it remains normal. If that number has slid I would ask for a cbc to see the retic number. Patrice

Patrice New York State

Patrice, Jan, Patrice, as always thank you for the information, I do appreciate it. There are just to many things to keep track of and to understand, and you certainly make it possible for at least me to understand. I do understand that the Imuran can suppress the immune system, but really thought being 3 months into it that she was safe. Like I said before I guess this is something that Holly's internist in Atlanta has drilled into my head, she wants her retic to be at 0. Her PCV has only gone up and down slightly so that was not a concern of mine, knowing that each blood draw can be different. But the retic has been on a steady incline since Sept 25, when it was 0.3/PCV 39.3, then 0.9/PCV 41.4, then 1.5/PCV 39.6. On sept 26 we went to 2.5mg prednisone EOD, and then Oct 26 every third day. So right now we are back up to 5mg in the morning only as of Nov 15 and will retest on Dec 3 PCV and retic per the internist and hope for the best. Jan, I am also thinking as the internist also said a slower reduction that maybe she will recommend 6-8 weeks and a slower reduction in mg. Maybe it all depends on what caused this also for them? Not sure for Holly if it was the parvo vaccine or the frontline as she was given both at the rescue. Linda

Linda Sapphire

This thread was discussed between 14/11/2007 and 20/11/2007

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