Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Indy and IMHA - Any Advice Appreciated

About a month ago, I took Indy - my 8 year old Italian greyhound (about 20 lbs) - to the vet because he had been acting strangely for the past few days: vomiting (more than usual - he has a sensitive stomach), unresponsive, limp, bright colored pee, refusing food and water. Upon arrival at the vet, he had a temp of 105 and his underbelly, along with his ears and eyes, were yellow. He also had a heart murmur. Basically right away the vet I took him to (I had just recently moved and did not have a new vet) knew what was wrong with him - IMHA. His bloodwork came back with off the chart liver enzyme levels and a RBC of 20%. She hooked him up to IV fluids and a Dexamethasone drip for the day. She also did testing to rule out a parasite infection. That night she advised that I could take him to an emergency vet to be watched for the night, or I could leave him there with no supervision except 1 visit during the night - and I opted to take him home to sleep in my bed with me. Well, he was definitely the only one who slept that night as I watched him like a hawk for any sign he may need to be rushed to the emergency vet. The next day I took him back and he was hospitalized for the day with the Dexamethasone again. Despite his apparent improved condition, his blood work came back lower than expected. Because of all the fluids and food coming into his system his RBC dropped, but it was all the way down to 12%. When I was able to take him home that evening, I was told he may or may not survive the night. I asked about doing a blood transfusion, but my vet thought that either he would improve and respond to medication, or he wouldn't and the transfusion(s) would just prolong the inevitable. After reading all the websites, I now probably would have gone ahead and done it - but I followed my vet's advice. She gave me 20mg Prednisone pills halved to give one half every 12 hours, some Carafate for diarrhea, and a 10-day dose of antibiotics just to cover our bases. Indy made it through the night and the weekend, and on Monday his RBC was up to 15% and he was in great spirits so we thought all was looking well and we set up another blood check 3 weeks later. During those 3 weeks, Indy seemed to becoming more and more himself everyday - jumping up at the windows to bark at birds, following me around the house, playing with toys. He has always been a couch potato so his laziness is nothing new. When I brought him back in, I truly expected a positive change in his RBC and to eventually start tapering the Prednisone. However, his RBC is back down to 12%. My vet has added an Imuran dose and we will be checking his blood work weekly now. I am just at a total loss. For the past month I have spent almost every single minute with him - I am lucky enough to be able to bring him to work with me. At this point, I feel like my whole life has become Indy, and I was finally starting to feel some relief but now that has been shattered. I just don't know what I would do without him. I know I need to stop worrying - whatever happens will happen - but now I'm even worrying that my worrying is making him feel worse! Any advice is much appreciated - thank you! Sorry for the long post, wanted to make sure I got all the details in.

Indysmom Pittsburgh

Indysmom, so sorry to hear your pup was diagnosed with this disease. My first thought is that the prednisone dose could be raised some. Perhaps 15mg twice daily would be better. What's the dosage of the azathioprine (imuran)? A crit (hct/pcv) of 12% is dangerously low and to me would warrant more frequent checks to the vet. I'd be wanting to go at least every day or two until it climbs to a safe level. I'm already not a fan of this vet. For a vet to say that a transfusion is pointless and will only prolong the inevitable is full of it and extremely inexperienced. NOW...with regards to the level of pred being used...you'll have to be VERY VERY carefull with the dosage you choose to use. With high liver enzymes it may be better to correct this first. Did the vet give you anything to remedy the liver damage? If not go TODAY and ask for a product called Denamarin. This will help the liver to heal. In the meantime you can ALSO add milk thistle to the daily diet. If the liver levels haven't been checked since this would have me worried! Have these recheckes sooner than later. This will help determine proper dosing of drugs. Have you considered reaching out to a specialist for advise? I'd STRONGLY recommend you reach out to Dr. Dodds and hemopet. You can send a sample of blood there for relatively cheap in the US. Trust me...it's worth every single penny. If you'd like I can help you figure out how to send it off. Dr. Dodds helps so many of us here and lots of us can say that our pups are here because of her! Also, by sending blood to her you can get a breed specific thyroid panel done. I bet your vet hasn't checked the thyroid. I personally think you should also add a good hematinic to the daily food. A hematinic is just a vitamin/mineral supplement that provides the bone marrow with the micronutrients that are needed to build baby blood cells. Without the proper amounts of these nutrients the body isn't able to respond properly to the call for more blood to fill the gap. Lots of us here use a product called Pet Tinic. You may have to call around till you find this but it works really well. If not you can supplement with Bvitamins, iron sups and folic acid. All of which are needed to build and make blood. Carafate is a good idea. Giving the meds with food is also a good idea. Food...feeding a healthy diet can be key when treating autoimmune diseases. What do you feed foodwise? Do you have copies of recent bloodwork? If not go to the vet and get copies of EVERYTHING. That way we can help to explain things to you. Certain things are needed...reticuloyte counts, spherocyte counts, platelet counts, etc. I'd be keeping him calm and rested also. With levels this low AND a heart murmer you should be taking things slow. Avoid ALL stress with him also. I'm sure I'm missing or forgetting somehting here. If I recall anything else I'll add it later. My thoughts and prayers are with you both. Johnny Tessy Sadie

Johnny

I am so very sorry to hear your dear Indy has been diagnosed with IMHA. While AIHA/IMHA is a very difficult disease, dogs CAN and DO survive it and go on to live happy healthy lives. If you have not read my Web site on Canine AIHA/IMHA as yet: http://www.cloudnet.com/~jdickson/ I would urge you to do so. Be sure to follow the links at the bottom of the first page to many more sites on AIHA/IMHA that will be very helpful to you and do read the SUCCESS STORIES pages. They will show you what has worked for other dogs in terms of treatment options as well as give you a lot of HOPE. With a PCV of 12 has your vet revisited the idea of a blood transfusion. Blood transfusions can buy time until the medications used to treat the disease start to work. According to the veterinry drug handbook it can take up to 6 weeks to see a clinical response with Imuran. We do see that drug start to work sooner in some dogs but in some dogs it can take the full 6 weeks to kick in. Has your vet mentioned the drug cyclosporine to you? If not I would have to wonder why not. That drug works well for many dogs with AIHA/IMHA and it starts to work much sooner then Imuran. With a PCV of 12, I certainly would not wait a full week to have more blood work done. With a PCV that low I would be doing blood work every other day or so to make sure it does not drop even lower. I am sure others on here will chime in with comments for you. Please be assured you and your dear Indy are in my thoughts and prayers during these most difficult days.

Joanne MN

Thank you so much for your responses. I did forget to mention that at the last test yesterday, Indy's liver enzymes are back in the normal range. Indy has always loved to eat, but he is especially eager with the Pred. I have been feeding him Fromm's Surf and Turf dry food, and Merricks canned - about a half a can a day. He's also been getting "safe" table scraps because at this point I can't bear to deny him. I have most of the copies of the bloodwork - I will pick up the most recent tonight and I will find out the Imuran dosage. Honestly, I really haven't thought a ton about all of these treatments - before yesterday's test, I really and truly thought he was getting better because his behavior has been consistently improving. Also, while at the time I wasn't totally sure of my vet, I thought that what she was doing was working. I appreciate any information you all have to offer - and yes, Joanne, I have read through your very informative website - especially the success stories, which are definitely hopeful, but also really scary.

Indysmom Pittsburgh

I would strongly recommend that you get a second opinion from a qualified vet who understands IMHA. I would think that Prednisone should have been the first drug of choice, in a larger dose, in combination with cyclosporine at the initial diagnosis. Imuran can be added to this combination if you were not seeing enough of an increase in the PCV, although it will take about a week to start working. A blood transfusion can buy time until all of these drugs start to do their jobs. The vets I took my dog to said we should not taper off of any drugs until the PCV is in the normal range for at least 2 weeks, and then to taper off very slowly. This can take months. We had blood work done two times a week for the first 2 weeks and then every week until we saw a constant increase in the PCV. We then went to once every month. This can be very expensive and takes a very long time. Please try not to worry so much. You are doing everything you know how to do to keep your dog with you. Ask questions, just like you are doing now. Make sure whatever vet you choose gives you answers to all of your questions and if you aren't satisfied, ask another vet or you can ask the people here. I'm praying for you. Ronda

Ronda Illinois

Also! On the first day Indy had an X-ray to rule out any enlargement of the liver or spleen - the x-ray was normal. I think the vet believes that the Prednisone is working, just not quite enough basically, since his RBC only dropped 1% a week or less. The hardest part of all of this to me is matching his behavior with the test results - they simply do not match up. And finally, finances and Indy's (and my own) quality of life are definitely concerns for me. And if you want to see some pics of my baby: http://picasaweb.google.com/lsreid/Indy?feat=directlink

Indysmom Pittsburgh

Another update: I went to pick up the copies of the blood work (scans coming later) and to speak with the vet. I voiced some of my concerns: I asked about increasing the Pred dosage to every 8 hours - so now he will be having a total of 30mg daily - for a few weeks until the Imuran has a chance to really start working. In conjunction with that, I will be giving more Carafate to help protect his stomach. I asked about Cyclosporine, but the vet said that she wouldn't recommend it and from her experience the best way to treat is with Prednisone and Imuran. The dose of Imuran was compounded to 18 mg/ml and I am to give 1 ml per day. She also said she wouldn't recommend blood testing more frequently unless he starts acting off. Today was not one of his best days, but he was still pretty happy, and super excited to see the other dogs at the vet (I tried to not let him get too excited). The vets reasoning in all of this is that she is treating the patient not the test results. While the test results reveal that the medication isn't working as well as we had hoped, Indy's demeanor is much improved. She said that animals are capable of adapting to a certain extent. In some ways I agree with her - he seems well, and if he starts acting weird, I can rush him to the emergency vet. Another thing I am thinking about is that I have to face the reality that he is going to pass away one day, even if it's not from this. And he is not a puppy. I want to do what I can for him, but I don't want him to be miserable - and I don't want to be miserable either. That being said, I do think I would like to take him for a second opinion. Does anyone know if the vet will look at the blood test results I already have and just do a physical exam? Also, what would be the best way to find a specialist in my area or a doctor who has extensive experience with IMHA? Thank you all so much for your support! :)

Indysmom Pittsburgh

Find a board certified vet diplomate here: http://www.abvp.com/find_results.aspx?city=&state=PA&lastName=&practice=&practiceType=Canine%2FFeline&Submit=Submit If this fails to return the same info as I have found for PA, repeat the search at this page and enter PA as your state: http://www.abvp.com/FindDiplomate.aspx my best patrice

Patrice NYS

Also here: http://www.acvim.org/websites/acvim/index.php?p=228

Patrice NYS

Thanks Patrice! I found a doctor that looks exciting to me: http://www.pvs-ec.com/internal_medicine/doctors.php - Sherwood Johnson - it says he specializes in immune-mediated diseases. I plan on calling first thing tomorrow morning to see if I can speak with him and make an appointment for a second opinion. I'm honestly kind of disappointed that my vet didn't recommend them in the first place. Also, I have scanned and uploaded Indy's full blood tests. They are in order from most recent, to oldest. They are hard to read unless you zoom in: http://picasaweb.google.com/lsreid/IndySBloodTests?feat=directlink

Indysmom

You cannot go wrong with an ACVIM Diplomate, they are internal medicine specialists. They spend a lot of years in school and residency to get where they are. Just watch that they don't repeat any tests unnecessarily. They may prefer their own test results. A special anemia panel blood test would be understandable, but I wouldn't want to do any invasive tests twice because it might be hard on my dog. If you can stay with Indy at ALL times that would be preferable so you can keep your eye on her. Always look confident and smile when you mention you want to be with her. Be calm when you are with her and act like you hang out in vet's clinics all the time. my best patrice

Patrice NYS

There is significant reticulocytosis (a high number of baby blood cells are being made) on the Aug 23 report: 8% and 122,400 absolute. This indicates good regeneration in the bone marrow. You should see a significant rise in the number of red blood cells within the week. The PCV will climb quickly unless there is continued destruction of red blood cells, though this seems unlikely at this point. They have dropped the TBIL total bilirubin, off of the more recent tests. This is an indicator of a large number of destroyed red blood cell's parts circulating within the blood and is the cause of the yellow color in the skin and eyes. (It is heme, the red coloring, inside the red blood cells floating free) This number was high back in July indicating RBC destruction. Lymphocytes are low, these are the T killer cells that you are trying to suppress. A good thing. It appears that in the early August test the neutrophils were high, thus indicating a possible infection. This could be a reason for the severe anemia, an infection. Those numbers have returned to normal, thus indicating a possible resolution of the infection. The chemical screen from Aug 23 shows all values have returned to normal except for a slightly high ALKP alkaline phosphatase. This would be a liver enzyme that indicates some liver damage occurring from the drugs. The liver is regenerative and will heal from this. It is nice to see all these chem screen numbers settle out into normal. Platelets and basophils remain a bit high but not by much. A slightly high platelet number can occur if Indy is dehydrated when they do the blood test. This would be ok and this slightly high number I would not worry about unless your vet mentions they want it a little lower. Basophils, which are white blood cells, can sometimes be on the high side when there is some kind of parasite infection that the body is fighting. They have remained high for quite a few blood tests, so there is something to this. Ask your vet. If they haven't tested for tick diseases and done a complete travel history I would be very surprised. my best patrice

Patrice NYS

Hi Patrice, Thank you so much for your interpretation of Indy's results - you've actually given me a lot of hope that things are actually heading in a better direction than I thought. With Indy's increased reticulocytosis (much higher than even the test from Friday where his count went up over the weekend), increasing the Pred, and adding the Imuran - I feel pretty confident that Indy will have a RBC increase this week - or at least be stable - which is much better than what I had previously thought. I think they dropped the additional few items off the test because it makes the test cost more - I didn't ask them to. Indy's coloration is back to normal, and since his liver enzymes are almost all the way back to where they should be, there is not really any reason to worry that his bilirubin is still too high in my mind. All along the ALKP has been the highest one - so it makes sense to me that it would be coming down more slowly than the others, and what you said could also be true. I looked more into Basophils to learn more about it - it seems that it is present when there are parasites or allergies. Indy was screened for parasitic infections and treated with an antibiotic so I am leaning more towards the allergies - because he does like to lick his chest and legs a lot (hes always been like this) but I'm also thinking that maybe it is some parasite that the test didn't test for (probably too much of me watching that Monsters Inside Me show). Thank you so much again!!

Indysmom Pittsburgh

This thread was discussed between 24/08/2010 and 25/08/2010

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