Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Maggie's first day home

Well, we will celebrate the small improvements. Maggie is very tired and still has a lot of healing to do. She mostly wants to lie or sleep in the corner. I am trying to just let her rest. Her muscles are all atrophied. One of the emergency techs said that she'll probably need a week just to recover from her hospital stay. You should see how scrawny she is. And while two of the medications are just aspirin and generic pepcid, she is on 8 total different meds this week, including one injection (Lovenox) that I have to administer every 8 hours. The first time was the worst. Hopefully, we can at least get her off the injection after this week. I believe that is among the worst in terms of side effects but is also preventing a recurrence of the scariest and most deadly possible conditions, a thrombotic embolism or emboli. We feel pretty strong that side effects from Prednisone (Cushings) contributed to the clots, so her dose was reduced from 80 to 20 mgs. The side effects were harder on her than the anemia itself. And they made her blood platelets hypercoagulative. That being said, it looks like we've made a breakthrough on her anemia (PCV of 26 on Sunday, 30 on Monday) and she is on two other (non-steroid) suppressing meds that will help her continue to make progress in this area. She is also being treated from acute pulmonary hypertension and acute congestive heart failure that seem to be resolving now that the clots are dissolving. Her lungs and heart just need time to heal. So one day at a time. The goal is to get her 100% back to her hiking, swimming, wagging, silly self. Every so often I see a glimpse of it. Thanks for all of your support. Maggie and Robert

RobertN Superior

That's great Rob. Swimming is a great way to rebuild muscles so that's excellent that she enjoys it. Consider searching for a hydrotherapy center in your area.

Monet Sammamish

Maggie's numbers continue to improve. Sunday PCV - 26 Monday PCV - 30 Saturday hematocrit 23 Monday hematocrit 27 She is still regenerative, however her reticulocytes have gone down. The vet says this is actually a good thing but I did not have the time to ask why as I was on a conference call on the other line. My only concern is the vet wants to INCREASE her cyclosporine dose from 200 to 400 mgs a day. I put in a call to discuss this as Maggie is already on so much medication and her numbers are getting better. This makes me uncomfortable. Ideas?

RobertN Superior

Robert, review my posts in this thread: Maggie's mixed results on 1st CBC. I present information about reticulocytes. This will answer your questions. Write Jean Dodds about the increase. She advised me with Chance (at 98 lbs) to dose no higher than 220mg. Once you push the cyclo dosage up beyond the generally recommended (tested) dose by weight you may see some undesirable side effects, which you can review by opening the Atopica product insert link I posted. My personal opinion is that it has done the job it was intended to do, decrease the number of rogue T-cells. Review the numbers on your last CBC and see if the lymphocytes are at a low number, this is exactly what you want. See Jean Dodds protocol on bone marrow failure, she lists the exact number of lymphocytes you want to see. What is left now is for Maggie's body to get stronger and finish the job of making more cells that she has clearly started. That takes serious home care, around the clock, good nutrition and low stress. Higher doses of meds may make her feel worse. But please write Jean. She will give your her expert advice for free, if you wish, and I would trust her if this were my situation. my best patrice

Patrice NYS

Patrice, Yeah, I remember you as well as my vets telling me that reticulocytes are responsive to the level or RBCs and they will be approximately 1% of the total count of RBCs. Frankly, I am freaking out given Maggie's recent brush with death concerning the blood clots. I hope this isn't an act of desperation following a test result that they have yet to disclose to me. The increase in dosage is being recommended by the emergency internal medicine specialist so I have to listen to her reason. I am hoping that she just wants to see if we can get the hematocrit up faster so as to get Maggie off some of her other meds, including and especially the Lovenox injections. I am open to a temporary increase, but one so drastic? It was a tech who shared the recommendation to me. She did say that if Maggie vomited, just to go back to the normal dose. Maggie and Robert

RobertN Superior

Robert, Does Maggie's RBC morphology show evidence of continued destruction, spherocytes? (I may have missed this in an earlier thread). Bentley's ongoing destruction was the reason our specialist increased his dosages of immuno suppressants, including the cyclosporine. Saying prayers for your sweet girl's continued recovery, Sally and (angel) Bentley

Sally Louisiana

Sally, The tech only gave me the HCT and the fact that the reticulocytes were lower, which they said was good. I was on a conference call on the other line that I interrupted, so I did not get the full response. Overall, the vet would have been a better person, because I did ask the tech if there was still an immune response and she did not know. She has not yet had spherocytes. Perhaps that is something new that has triggered this requirement. Her lymphocytes have always been on the low end the past two months. I would guess that there is still some immune response. I do have to say the tech said that if Maggie was sick from the higher dose, just go back to the lower dose. She sounded like it would not be a big deal. So maybe they just want to hurry the process up. Since I have not heard from the DVM, I complied with her protocol adjustment. 50 minutes later, and Maggie is doing great. Actually, she is doing really good in general, given what she's been through. Much more herself, even since this morning. My guess? Maggie is doing fine, with the bad boy T-cells in retreat, but that the DVM wants to reduce Maggie's complete medicinal protocol as she is taking a good number of medicines. I am a very optimistic person. Thanks for your responses, Maggie and Robert

RobertN Superior

This is different than the hemolytic destruction that is experienced with AIHA/IMHA. In this case the bone marrow ceases to make or destroys the precursor cells (inside the bone marrow) that are eventually made into red blood cells. Red blood cells in circulation live about 120 days and then age out. In a normal body they are gradually replaced, everyday, by the bone marrow. In Maggie's case, the cells were aging out and were not being replaced. This is called normocytic anemia. A blood smear will show this clearly. In other words the red blood cells in circulation are normal and they are not being destroyed but there are less and less of them as time goes by. So therefore, the signs that you see in AIHA, like spherocytes, are not usually seen in bone marrow failure. It can be autoimmune in nature, but it is a different disease. Golly, I would consider her current response to anemia to be very successful. She has gone from 26 to 30 in just a few days! I have seen plenty of dogs on this forum survive for as long as two years with a pcv in the mid 20's! This isn't as simple as turning on a water tap full blast. It's a very sick body beginning to relearn how to make blood cells. Maggie has had a very very very serious bump in the road, but the bone marrow is responding! Of course, I can't see the blood work or other test results, but common sense tells me that she is recovering. Remember, I was there with Chance. He was "that" sick (near death), but his blood work showed this similar recovery. Dr. Dodds and my vet both agreed that it was a very good sign. We didn't feel any need to increase his meds, only maintain them where they were. He even knew he was getting better! I kept him at home, in a low stress environment with plenty of round the clock "mommie" care. His vet was only 15 min away. Everything in the body needs to work together to have this situation improve and that means rest and good nutrition. I still think you need to write to Jean. She may have some rational for the need to increase to twice the normal dose that I am unaware of. I just personally don't agree because I have seen the study results of the side effects of a double or triple dose of cyclosporine. Does it have to happen so quickly? Can they give her a few days at home and re-test before they make a decision? So, no, I don't agree. This sounds too drastic. And if this were me, I would want to know what Jean has to say. Email her tonight before she gets off for her holiday and is harder to reach. hemopet @ hotmail.com. my best patrice

Patrice NYS

Patrice, I just wrote Jean. I almost wonder if the Tech mispoke or misunderstood the instructions. Maggie's initial dose was 200 mg to be taken at once during the day, not split each 12 hours. But the tech did say 400mg. I did give Maggie 200 mg for her evening dose. I may just give her the one capsule in the morning and just wait until I hear back finally from the internal medicine specialist. In the meantime, I am going to speak to one of Maggie's secondary primary care practitioners (works at Maggie's general practice). She at least can perhaps get to the bottom of this faster than me as DVMs will more likely respond to each other than to a patient's caregiver. I am THRILLED that Maggie survived such an event, and in awe of her regenerative powers. Even after one day at home, her silly Lab personality is emerging in increasingly rapid fashion. Maggie's main general practitioner, who is very straight spoken, sounded giddy the first time she spoke with me upon Maggie's release. Maggie's current resting respiration is at around 24. Her tongue and mucus membranes are a darker shade of pink than I've ever remembered. She needs lots of physical therapy and even more treatment for what are fortunately acute conditions to her heart and lungs. But she is a true blessing, a reason to be truly THANKFUL this holiday season. Thanks for being so attuned. She really captivated everyone at the overnight care hospital, just as she does at her general practitioner. Maggie and Robert

RobertN Superior

Robert, Have they done blood testing for Maggie in relation to cyclosporine? Meisha's Hope's page states that cyclosporine dosage may be adjusted based on how well the tissues are absorbing it, as this number can change over time. Here is the link to the page: http://www.cloudnet.com/~jdickson/treatment.htm Our internist said that there is a range for the dosing. Ours is 100mg-200mg and that is for a 45lb dog. 200mg-400mg sounds right for an 80lb dog.

Monet Sammamish

Monet, I think the question is why, especially if the current dose was already working so well? Well, I just learned not to feed her those rich chicken flavored medallions from Nature's Variety. May have been bit too rich. Maggie moved fastest I have seen her in awhile to get outside, poor thing! Robert

RobertN Superior

Robert, I just got home and checked to see exactly what we dosed Chance and for how long. He was on 40mg prednisone starting in early spring for 2 weeks and then bumped up to 80mg. There a gradual decrease until early November. After Contacting Dr. Dodds we started dosing Atopica on July 23, 2007 for 9 weeks at 225 mg Atopica and then at the 10th week Dr. Dodds had us drop to 150 mg for 4 weeks. 100 mg the next week, 75 mg the following week and ending with 4 weeks of 50 mg. I was also concurrently decreasing the prednisone and I suspect I was more cautious than I needed to be with decreasing the Atopica. His blood work was back to nearly normal by October. She had us give the doses Monday through Friday only, with weekends off. She calls this pulse dosing. It was extremely successful. Thus, when I asked her about having a trough blood test done to measure the effectiveness of the cyclosporine she told me that it wasn't necessary, the success of the treatment indicated to her that he was receiving the proper dose. A trough test is testing the blood level of cyclosporine at the very end of a 12 hour cycle. This is very important in human medicine for transplant patients. By late October his coat was beginning to return to normal. my best patrice

Patrice NYS

I misspoke. Dr. Dodds protocol mentions that in one study of 43 dogs with severe idiopathic nonregenerative anemia spherocytes were seen in 54% of the dogs. She does sometimes dose at a high rate (for dogs approximately 90lbs), 400 mg cyclosporine, but for one week only (the first week). She drops to the 225 mg dose the following week. She continues to cycle, 5 days on 2 days off at this dose for up to 3 courses followed by decreases. She feels it is safe and effective used in this manner. It was with Chance that she determined not to use the high (400 mg) dose his first week but started him at 225 mg. The high dose for week one would be considered a "loading" dose. Since you are already dosing Maggie, you are past the stage of needing a loading dose. She goes on to say that if this dosing isn't effective she will add azathioprine (Imuran) concurrently with the cyclo. my best patrice

Patrice NYS

I remember when charlie was on all of his meds, the side effects were horrid. he wouldn't eat, didn't want to drink and could not even hold himself up to relieve himself outside. he would have accidents in the house which is something he never did. In order to kill all the bad things you just about have to kill the dog itself, it is very scary -- they are chemo patients. i don't have any advice on drug choices or doses - every dog is so different -- i just want to offer encouragement, hang in there -- i honestly did not see how my dog could ever recover after being so sick -- and i know there was never a guarentee he would -- but he is slowly starting to return to his normal crazy self, the muscle return has taken the longest and i can still see him struggle with stairs if he is tired but slow and steady is how the recovery is going -- hang in there!!

charlie

Argh... Looks like the tech screwed up and misunderstood the notes. Maggie is to continue on her dosing of 200mg per day. Confirmed by the vet at Maggie's primary care hospital who just received the latest notes this morning. She has a call put in to the internal medicine specialist this morning, but she says according to her latest, as of this morning, no change in medicine protocol. And Maggie continues to improve on a daily basis; strength, energy, respiration and general demeanor. She is currently chasing bunnies in her dreams, something I've not seen for WEEKS! I do believe that she finally fully resolved her clots. She just sneezed out some clotted blood and immediately, her breathing has been MARKEDLY improved.

RobertN Superior

Woof. Good catch. It did not sound right to me. p

Patrice NYS

Good News RobertN, Happy that you caught it. A "tech" over dosed our little Daizee 4 years ago. She died of Cardiac Arrest. Keep it up Maggie, You can do it! RobertN, Continue asking questions when you suspect that something isn't right. Look where it got you. ;)

Kathy Calif.

Looks like you and maggie will enjoy a blessed Thanksgiving together. Glad you caught the mistake and all's well in this part of your journey. Blessings, Cindi & Tori

Cindi FL

Ugh... back to the original question. Hospital vet called and left a message, said it was good that her PCV was up but Maggie's reticulocytes were down so she felt there wasn't yet enough immuno suppression. She did not provide numbers. I am going to wait on the cyclo dosing. Something seems really inconsistent. Have a 5:10 appointment with Maggie's primary care provider on Monday for a full CBC. May go in Friday even though Maggie's vet is not in, just to get a PCV or maybe a CBC then hold the appointment for Monday just for an examination and possibly another CBC if Maggie's primary care vet thinks its warranted. I agree about waiting before acting on this. Maggie's body is still resetting. She is certainly stable after a recent CBC of 27 and probably still has enough reticulocytes and RBCs to keep her steady for the next 5 days.

RobertN Superior

Robert, This could be several different things. But I just want to remind you of what I spoke of before, that sometimes when you give a non-regenerative dog a transfusion, it can suppress the bone marrow for a time. If she has many robust new red blood cells in circulation, yes, she will be fine. Over this upcoming holiday, try to arrange to keep your household quiet and her environment stress free. Avoid any "special" treats from the table, curious visitors or pets from other households. I remember vividly this point in time when Chance was ill. Looking at the top of the mountain and wondering if we would reach the summit and finally coast down the other side. I lived on no sleep and total adrenaline. I was so frightened. I did not know the future. I alternatively wanted someone to talk with and then I wanted to be alone with my grief. I had to curb my urge to constantly be around Chance and give him space. I had to trust that his body was struggling to get better and I just needed to give it time. my best patrice

Patrice NYS

Patrice, Thanks for sharing your experience. Fortunately, the holiday festivities are away from home. So Maggie will have a peaceful Thanksgiving. I have modified my visit schedule to match her medicinal needs. She is showing very well and actually moved rather quickly on her potty trip outdoors last night before bed. I just counted her respiration and it is at 20. She greets me with the typical lab wag. I will bring Maggie in to the vet Friday for a quick check up but my bet is that she is still resetting. The emergency hospital vet pulled Maggie through the emboli crisis by being aggressive and it saved Maggie's life. Maybe that is just her veterinary style. In her message she also mentioned the option of waiting and seeing what Maggie's PCV/CBCs show either Friday or Monday. So I will just sit back and by fine with my decision. In the meantime, Maggie continues to get stronger by the day. Thanks again, Happy Thanksgiving Maggie and Robert

RobertN Superior

Sounds like Maggie is in good human hands! keep up the great work, go with your gut, well done on the over dose catch! Happy Turkey Day,

charlie

Ok, sorry to interrupt Thanksgiving, but I listened to the emergency care vet's voicemail again and she specifically states that while Maggie's PCV is up "which is fantastic" her reticulocytes are still elevated just not to the level they were before. This is exactly what Maggie's primary care vet said would happen as well as what Patrice described happens in another thread. Reticulocytes decline as the mature RBCs increase. The emergency care vet did not say what the reticulocytes were at, just that they are "still elevated, just not at the level they were at before". She also said we could wait to see what Maggie's next CBC reveals or redose bigger capsules so Maggie did not have to go all the way up to 400 mgs. This is what I'm going with. I fully expect Maggie continues to be regenerative and that the reticulocytes are responding accordingly to the RBCs in Maggie's blood.

RobertN Superior

RobertN, How are you and Maggie doing tonight? I think of all of you so often. I lurk here everyday in Hopes of seeing a lot more success stories. Take Care, Kathy

Kathy Calif.

Robert, When I first studied to understand reticulocytes I made up a little story for myself so I would have a way to remember how it works. Perhaps this will help you too. Imagine you have a glass. You want to fill the glass with water. You go to the tap and turn on the faucet. You fill the glass. The glass will remain full until you either take a sip from it or the water begins to evaporate. It is a simple matter to go over to the tap and turn it in on very lightly to refill the little bit that is gone. Now imagine that glass has a hole in the bottom. You to to the tap to fill it and you are able to fill it but for some reason it doesn't stay full. It seems to need for you to keep running the tap water into it. Imagine the hole getting bigger. Ooops, you just can't keep up, you try to fill it, but it won't stay full. It is a losing battle. Imagine you are able to plug the hole up, but not very well. The glass fills up and seems to stay near the top but you notice leaking out of the bottom over time. So you need to go back and top it off more often. This is the way reticulocytes behave. Once the body senses that there are enough red blood cells in circulation, it slows down the manufacture of replacements (reticulocytes) because the "glass is full." However, if there is a "hole" the body attempts to replace the lost red blood cells as quickly as possible. The hole is the destruction of red blood cells. This happens either slowly as each day old red blood cells are destroyed normally or it happens very quickly as red blood cells are destroyed by autoimmune hemolysis. The replacement process is a natural response called reticulocytosis. It is driven by signals from body cells that they are experiencing low levels of oxygen. But what if the destruction of red blood cells doesn't stop? What if there is continued hemolysis? Massive numbers of reticulocytes are made in the bone marrow. The response is very high, reticulocytosis, in an attempt to replace those destroyed red blood cells. When a vet sees this on a blood test, an absolute reticulocyte number something like 500,000 but there is no increase in circulating red blood cell numbers, they know that there is something very wrong. This means that the autoimmune destruction is continuing unstopped. This is that glass with a huge hole in the bottom and the tap water on full. It is a very ominous sign. What if there is no replacement of old worn out red blood cells? What if the marrow fails to begin reticulocytosis? The glass begins to empty slowly as though there is evaporation of the water into the air. You want to top off the glass of water, but the tap isn't working. This is also a very ominous sign but in a different way. It's like the city turned off the water to your house. So there has been standardization of the numbers of reticulocytes that should be produced and circulating for each stage/degree of anemia. *This is the gold standard for measuring the seriousness of anemia.* When there are not enough reticulocytes for a certain level of anemia then they classify it as non-regenerative anemia. Try to avoid thinking of these numbers as static numbers. This is a dynamic situation. The happy little blue reticulocytes swimming around one day turn into full fledged red blood cells in about 3 days. They abandon their brethren and must go to work. They change their blue uniform for a red one. So to you and me we see a loss of something (blueish reticulocytes) but a gain of something else (red blood cells). It is a natural process and it is extremely dynamic. When we are healthy it operates slowly and deliberating. When there is anemia, it must speed up drastically. So your vet is concerned that the "tap" isn't running fast enough to keep up with the loss. You can only test frequently to find out what is happening and the test could show something different the next day! The success of this process is measured by relationships of the numbers of red blood cells, reticulocytes, and the measure of hemoglobin. They intermingle together trying to create a balance. And at this stage there are often many cell inclusions that mess up the balance. Cell inclusions are defective red blood cells that don't work quite right. They can be seen on blood smears and they identify problems that are happening with the process. Spherocytes for example are red blood cells with a "bite" taken out of them. The spleen, sensing that these cells are not "self" attempt to destroy them by pinching off a piece. Under a microscope they look like half moons. Blood tests also measure various indices about red blood cells. These measures are: average red blood cell size (MCV), amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood cell (MCHC) and hemoglobin amount per red blood cell (MCH). These are like flashing hotel signs, they tell a big story about the cause of anemia and how the recovery process is going. You will see, for instance, the MCV size rise significantly when there is significant reticulocytosis happening. These are large cells and that is reflected in the MCV value. If there is pernicious anemia (low blood iron), you will see pale cells and that is reflected in the MCH value. What is particularly ominous about non regenerative anemia is that these values are normal. The cells that were made before the bone marrow stopped making cells are absolutely normal. This is called normocytic anemia. At first glance it made no sense to me and I had to struggle to understand how Chance could have such normal blood cells but be so ill. I hope this has helped some. my best patrice

Patrice NYS

Patrice, Thanks for the analogy. I am once again encouraged that she said on the Maggie's reticulocytes were "elevated - just not to level they were before". I am bringing Maggie in for a CBC today to see if her HCT is still rising and also get a measure of other things in her blood, including reticulocytes, etc. If her HCT has leveled off or declined, and her reticulocytes are not responsive enough, I will go with the emergency vet's recommendation, and see if an increase of 250 from 200 mgs Cyclosporine is sufficient.

RobertN Superior

This thread was discussed between 22/11/2011 and 25/11/2011

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