Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - KEELI 'S CBC UPDATE/Advice Appreciated

Just got back from Keeli's appointment for blood draw. Had them do a CBC to see whre we are at. They told me that their machines would not be accurate on reticulocytes but had them do it anyway to see what was going on with everything else. Patrice I told you I would let you know what they found. Here you go. Some good and some bad news. RBC 4.30 5.50-8.50 Low GLU 100mg/dl 70-143 WNL HCT 32.7 37.0-55.0 Low BUN 34 7-7.27 HIGH HGB 12.0 12.0-18.0 Right at Normal CREA 0.8 0.5-1.8 WNL MCV 76.0 60.0-77.0 WNL BUN/CREA 43 MCH 27.9 18.5-30.0 WNL TP 7.1 5.2-8.2 WNL MCHC 36.7 30.0-37.5 WNL ALB 3.8 2.2-3.9 WNL RDW 16.4 14.7-17.9 WNL GLOB 3.3 2.5-4.5 WNL %RETIC 0.5% ALB/GLOB 1.2 WBC 7.86 5.50-16.90 WNL ALT 391u/l 10-100 HIGH RETIC 22.8 ALKP unable to read 23-212 %NEU 85.0% %LYM 7.1% %MONO 5.7% %EOS 1.5% %BASO 0.7% Let me know which direction I NEU 6.68 2.0-12.0 WNL should take from here. Have LYM 0.56 0.50-4.90 WNL giving cyclo every other day MONO 0.45 0.30-2.00 WNL and vet wants me to stop it EOS 0.12 0.10-1.49 WNL so am dc'ing it to see what BASO 0.06 0.00-0.10 WNL happens. Also added cipro for PLT 518 175-500 High some ulcers on the bottom of MPV 8.6fl her tongue. Vet thinks due to PDW 19.1% meds. Need your advice. PCT 0.44% Sincerely Joann and Keeli

Joann Binger Ok

LOL...I had a tough time reading but think i got the jist of everything now. The vet is thinking of stopping cyclo? What's the current meds and dosages? Were the numbers stable for some time now? You're very close to normal range now. It may not show in the HCT but the other numbers especially the hemoglobin show this. It may be now that the crit will rise very very slowly until it reaches its norm. Are you still using denamarin? I'd keep with it till the liver values get lower or normal. She's suppressed enough now so perhaps dropping the cyclo might be a good idea....depending what the other drugs are. I hope you're not still giving high doses of azathioprine are you? Given the low whites and low retics it may be the drugs causing bone marrow suppression. Lowering may be a good choice. Cipro....this is a big gun. If it were me I wouldn't use ot for any more than 2 weeks and even that would be pushing it for me! Always make sure to give with lots of food and be sure to give probiotics at least 2 hrs after giving it. Cipro works very well. You might also want to try flushing her mouth with camomile tea. It's great for them to drink and also has antiinflamatory/bacterial properties. Might help the ulcers heal a bit better. Are you giving any type of vitamin supplement? Pet tinic or B shots? My thoughts and prayers are with you both, Johnny & Tessy

Johnny

Hi Joann, Red Blood Cell Values: RBC 4.30 5.50-8.50 Low HGB 12.0 12.0-18.0 Right at Normal These are the red blood cell numbers. They show a little low on the total number of red blood cells (but certainly not by much.) They show the hemoglobin is sitting right at the lowest normal value. This is excellent. It shows that your red blood cells are maturing properly and have the correct amount of hemoglobin (which carries oxygen). The body cells like this because they are now getting enough oxygen and have stopped pressuring the kidneys to ask the marrow to make more reticulocytes. (As seen by the low value of the reticulocytes: %RETIC 0.5% RETIC 22.8) As far as the body is concerned, this hematocrit value: HCT 32.7 37.0-55.0 Low, is enough even though it is a little low because there is enough oxygen going to the cells. Do you understand this? Organizations like the American Red Cross evaluate anemia, not necessarily by the value of hematocrit (or PCV) but by the value of hemoglobin. If that value is adequate to carry oxygen, then the donor is considered not anemic. MCV 76.0 60.0-77.0 WNL MCH 27.9 18.5-30.0 WNL MCHC 36.7 30.0-37.5 WNL These values tell us what the red blood cell size is and what they contain. Their volume is still a little large (MCV) because they are just coming out of the reticulocyte stage of their life. They contain a higher normal value of hemoglobin (MCH and MCHC). Eventually these numbers should fall within the range more towards the middle. Right now they are all considered WNL (within normal limits.) WBC 7.86 5.50-16.90 WNL This is the overall value of white blood cells and it also is WNL. So there is no indication of infection or other inflammatory process. PLT 518 175-500 High This is the value of the platelets. It is high, but that can be an abnormality due to dehydration at the time of the test. Normally, a value like this, that isn't very high is purely because of dehydration. Since an overnight fast is best before doing a blood draw, this would be a common occurrence. In fact, many of the values can be a little different because of this dehydration. There is less fluid for all the elements of blood to float around in and that makes their numbers seem a bit higher. Chemical Screen Values: ALT 391u/l 10-100 HIGH ALKP unable to read 23-212 These two values are commonly associated with liver values, although they can indicate inflammation from other sources. But it's probably safe to say that this in direct relationship to administering prednisone. The liver must process this drug and in doing so it destroys liver cells and makes new ones. So the ALT (alanine aminotransferase) is high. The ALKP (Alkaline Phosphatase) says unable to read. This means that the vet should have continued to dilute the sample and put it through the machine until it could get a reading. Because of this I suspect that it can be anywhere from 1000-10,000. My dog's highest value was over 8600 but I have seen some numbers on this forum higher than that. It's worrisome, but not permanent if there was no liver problems prior to the administration of prednisone. The liver can regenerate these cells and recover once the dosage of prednisone is lowered. It is important to continue, at this point, with Denamarin to support the liver's efforts to resolve this inflammation. Once the numbers are closer to normal, then you can switch to something like OTC milk thistle and Sam-e. BUN 34 7-7.27 HIGH CREA 0.8 0.5-1.8 WNL BUN/CREA 43 These are kidney function values. The BUN Blood urea nitrogen is higher than it should be. The creatinine is within normal limits. These two numbers, when looked at as a ratio (BUN/CREA) determine the health of the kidneys to process waste and eliminate it in the urine. If a value is high, that means the kidneys weren't as successful at this job as they should have been and some of the wastes remain in the blood. So even if one number is normal, there still can be a ratio that is not considered normal. I am going to guess, again, that this is directly a result of dehydration at the time of the test. If this were me, however, I would want to know at the next test that the BUN value has improved and that CREA is still normal. If you see any changes that indicate higher values you should discuss this with your vet immediately. If there is any hint of kidney disease, this would be the best time to treat that. I am not a vet and cannot tell you if there is a problem or not. Your vet should evaluate and let you know. Some ulcers on the bottom of her tongue. Vet thinks due to meds. Need your advice. Yes, your vet is probably correct. This is most likely a side effect of either the prednisone or the cyclosporine. If this begins to interfere with appetite and eating they will need to treat. It's hard to get dogs to rinse their mouth, but your vet may offer you a sample of doggie type mouth rinse or toothpaste that might help. I would continue with the antibiotic to help improve these sores and prevent them from becoming infected. So overall, things look very good. I think the next test is very important. You should see a slow gradual rise of the red blood cell numbers to normal values and a hematocrit around 37-39. If this is not the case and it stays steady, then continue to evaluate the blood regularly to make sure it is staying stable. A value of HCT 32.7 (37.0-55.0 Low) is not generally considered normal, but Keeli's body seems to be doing fine with this. There is no requirement that all dogs or humans fall exactly into a certain range if they are healthy. If, however, you begin to see a slow gradual decline in these red blood cells numbers (and a reticulocyte number below 60,000 or 1%), it might indicate a non-regenerative state of the bone marrow. It would be wise at that point to return to an aggressive immunosuppressive treatment protocol. I have been there, done that. If you see a rapid decline in these values your vet will need to re-evaluate any decreases they have made in meds and consider this a relapse and treat accordingly. While it's not my place or your job to harp at your vet about treatments, it is good to know what you are seeing on these tests. The numbers generally don't lie and there is a good reason for them to be what they are. There are many variables that come into play when a blood draw is done, how the tubes are handled and how the sample is prepared for the automated analyzer. These things can introduce errors that you may not understand. But a vet should always question these numbers that might be due to errors and help you understand what this means. If you have some familiarity with the meaning of the values then you can ask the right questions. Do you have any questions? my best patrice

Patrice NYS

Patrice Thanks so much for your help. Though I am a nurse, lab values sometimes confuse me and I don't know all the correlations between them without extensive research. I do understand the perfusion of oxygen to the cells and organs and the importance of maintaining this. I have been so worried that things were not right. I am very happy that I requested a CBC this visit to get the full results. This brought it all together for me in a way I understand. I will monitor everything closely and make sure there is no regression after discontinuing the cyclosporine. Am a little nervous about stopping this med but I know we need to do something due to the mouth problem. You will never know how much I appreciate your assistance with this. Wasn't sure if its ok to give the cipro at the same time with the pred and azothiaprine. I have read about drug interaction with cipro and prednisone and causing tendenitis and other issues. Do you know anything about this and should I give the cipro at a different time? All the other meds and dosages have remained the same. Am still using the Denamarine at this point as you said. Will let you know of any changes. if you have any other advice or see anything I can do to improve things please let me know. I feel like I'm taking alot of your time on this but I do appreciate your help. You are teaching me alot. Thank you so much for everything. Best Wishes Joann and Keeli

Joann Binger OK

Johnny Thanks for your input. All Keeli's meds have remained the same and yes she is still on the Denamarine. She will only be on the Cipro for 7 days and we are giving it twice a day. I will not keep her on it any longer and will do as you and Patrice suggested and ask about a mouth wash or chamomile tea. Haven't heard of that before but I can see where it would soothe. It hasn't caused any problems with eating or appetite at this point so that part is fine. Keeli has been on the Pet Tinic from the beginning and will continue with that as well. Will not change anything except for the cyclosporine at this time. Thanks so much for getting back to me on lab values. Joann and Keeli

Joann Binger Ok

If you prefer not to use ciproflaxin, ask if cephalexin will be an adequate substitute. It is a broad spectrum antibiotic and I have used it safely on my dogs for various skin ailments. I know plenty about the risk to ligaments from using cipro in humans (and this effect can last long after the doses have been administered) but I know little about it in canines. I can't assume it has the same effect. Good that you are a nurse! You then will understand the effects of dehydration on blood tests. Also keep in mind that prednisone redistributes body fluids (and fats) and that can lead to symptoms of dehydration. I remember one day lifting up the nape of Chance's neck and was horrified that it stayed in a peak long after I let go..... Ask your vet if on the next chem screen if they will do a mini-chemscreen (just kidney and liver functions), it will cost less. Also ask them to dilute the sample and rerun the test to get that ALKP number. I think my vet diluted 3x to get 8600. You are probably also aware of the very strict reduction that must be done with the prednisone? The adrenal glands shrink after prolonged use of prednisone and must be "teased" back to full function slowly. If you decrease too quickly, and the adrenals are not prepared to produce the required cortisol levels, you might see an Addison's/adrenal crisis. When you finally reach about 2-5-10 mg per day or eod (depending on the weight of the dog) you are into subclinical dosages and there is very little immunosuppressant activity. my best patrice

Patrice NYS

Patrice Keeli is on 125mg 2 x daily of Cipro for 7 days. Will go ahead with this for now but if she has to be put on anyting else will ask for cephalexin. That worked great when her stomach was such a mess. It cleared right up. I have read that the prednisone should be reduces 25%-35% each time but can you give me the exact time period of reduction. Keeli weighs 25 lbs right now. Am not reducing pred at this time but do want to know how it should be done so I will do it correctly when the time comes. I questioned my vet about the cyclosporine being withdrawn from eod to none and he said it would be fine. What do you think? Is it ok to just dc it with no withdrawal symptoms? Will ask for the mini chem screen and also about the dilution on her next scheduled visit. Thanks Patrice for the time your taking to answer my quesitons. We are both very greatful Joann and Keeli

Joann Binger Ok

Well, the usual course is to reduce the prednisone first and then the additional immunosuppressive drug, in this case cyclosporine. The reasoning being that the side effects of the prednisone are systemic and cumulative the longer the high doses are continued. It takes a very long time to properly decrease from a very high dose of prednisone. Meanwhile body systems are taking a beating. There are very few side effects from using cyclosporine and nearly all of them diminish immediately once the drug is decreased and removed. In some rare cases this is not true, there are some folks here who have seen some rare skin conditions that took a long time to recover from. But the studies I read where they dosed the dogs at as much as 10 times the required dosages (for use in canine atophic allergies) most side effects were gastrointestinal and few to none dogs in the study had serious life threatening side effects. The immunosuppressive dosage seems to be nearly the same as the loading dose for treating dogs with alleriges so it's not anywhere near 10x the standard dose! So Chance, at around 95 lbs, was started at 250mg Atopica. That is the high loading dose for a dog with allergies! So he was dosed no higher than a dog with allergies. If I had dosed him at 10x that dose it would have been 2500mg! Yikes! So, no there is no reason not to gradually decrease the cyclosporine. But yes, pick one drug or the other and decrease that one down to a certain point and then alternate with the other drug, with the ideal of getting the prednisone down to 2-5-10 mg every other day eventually, depending on weight. The best guidelines I have seen, and what Dr. Dodds usually advises, is to decrease the prednisone (or other drugs) no more than 25-33% at one time. Precede each planned decrease with a full CBC for proper evaluation. Unless it is medically necessary, do not decrease any drug more often than 2 weeks minimum. Usually you will see great reduction in side effects once you reach prednisone dosages around 15-25mg (again depending on the dog's weight). This is the low end of the immunosuppressive dose. Obviously for a little tiny dog this is very high, for a big dog like mine, it is low. When determining the 25-33% reductions, figure this out OVER A WEEK'S PERIOD OF TIME. Let's say we are at 100mg a week (14.2mg a day), 25% of that would be a decrease of 25mg over the week. So 100-25=75mg a week. Divide the 75mg by 7 days equals 10.71mg a day. Do you drop to 10mg or go up to 11mg? And how do you divide that up in a day? Once a day or twice a day? What size pills do you need to do this? Can you actually figure out how to get .71mg of a pill?? Having a larger weekly figure helps you round the total amount a little easier than trying to figure it out daily. The goal was to get 75mg as a total dose during the week, not necessarily 10.71mg a day! So you may end up doing a decrease during the week that is closer to 33%. So you could dose somewhere between 70-80mg a week. Now you don't have to measure each tablet with a microscope to cut it. In this case I would be apt to use 10mg a day, divided morning and night, but you could easily go to 12.5mg a day (a 10mg plus half of a 5mg). When the dose gets to very low doses, dose in morning, just as our body provides us more cortisol in the AM to go about our busy days. Follow me carefully here, the adrenal glands normally produce the same cortisol that you are giving artificially. It is needed for many body functions but is best known for "flight or fight" preparation. Increased heart and breathing rate, more blood flow to the muscles, more sugar into the circulatory system etc. When you give more cortisol via prednisone, the adrenal glands say "ok, I see you are taking my job, I'm going to take a nap." And they get small and ineffective. The body struggles with the excess like it is always on alert, it is very stressful to the body. If you don't do this decrease slowly and your dog is stimulated (fight or flight) to chase a squirrel in the yard suddenly, the adrenal glands are not going to be able to provide the correct amount of cortisol needed to make all these things happen in a stressful situation. The dog may have an Addison's or adrenal crisis. They can be dangerously ill very quickly. So I can assure you that every doctor and every vet knows how to decrease prednisone safely. Some vets might even be more aggressive than the owner can bear to watch so speak up if it bothers you. The vet will probably allow you to slow down the decrease, but they will never want you to speed it up by yourself. They are the professional, let them help with this. The purpose of going to an every other day dose EOD is to coax the adrenals to start doing their job. This kind of dosage happens very late in the decrease schedule. You may be giving 2 or 5 mg EOD and then 1-2.5 EOD etc. Some owners are so worried that rather than just drop it they will go to an every 3 day dosage. Dr. Dodds advises some owners of dogs that have had an especially difficult case that they may never be able to completely eliminate the drug altogether. Some dogs, when they get down to the lower doses, suddenly seem ill and getting worse to the owner! What a shock to get your dog well again only to find them sick (as a dog). This may happen because prednisone is used to treat many many other conditions. Your dog may have arthritis or inflammatory bowel disease and the prednisone was helping reduce inflammation! Your dog may have a true form of Addison's disease and they really do need the cortisol! So be aware of these scenarios. My dog had severe allergies all his life and was on allergy shots for many years. When he got better and I reduced his meds I was worried that he would suffer allergies again. I used a drug commonly dosed for these allery dogs called Temaril-P, which contains a small dose of prednisone plus another drug. But I could have just as easily continued to use cyclosporine (Atopica) for him as well. Sorry this sounds so muddled. I am distracted. my best patrice

Patrice NYS

Patrice Thanks again for giving me your time to explain everything. Will give you a rest for awhile and work on all of this. You have been most helpful. Sincerely Joann and Keeli

Joann Binger Ok

This thread was discussed between 10/09/2011 and 12/09/2011

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