Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Mo with AIHA and a low iron level

Hi guys, following all of your wonderful help and support I am wondering whether you might have any guidance on our current position with Mo. After having been diagnosed with AIHA in the first week of March, she is now on prednisone, cyclosporin, cellcept, aspirin, heparin and stomach protectant. Her pcv has risen to 28 but has not moved in weeks, and the vet has now identified that she has a low iron level which he says is unusual for AIHA. He is testing her for internal bleeding via a faetal test next week (we have to avoid any meat for three days). Is this unusual as he says? And does anyone know of any other reason for low iron if it not due to internal bleeding? On the plus side, Mo is stable, but she is tired and lethargic and still cant climb stairs or jump on to the sofa as she used to. She is also not very cuddly while it used to be difficult to stop her cuddling! Thanks for any help/guidance you can provide Diane

Diane Milton Keynes

Diane, There are several reasons why the iron level can be low. Can you identify the testing that your vet used to arrive at this result? Do you have the lab results? This value is referred to as the ferritin level. Cobalamin (B12) and folate (folic acid, a B vitamin) are also usually checked with this panel. All three of these are essential for proper blood manufacture. And sometimes it is not possible to raise these levels with dietary supplements. This is because they are absorbed in the small intestine with some helpers. In dogs, digestive disease in the small intestine is a common cause of this. If I have heard the acronym SIBO once I have heard it a hundred times. Small intestine bacterial overgrowth. These dogs have too much bad bacteria in their small intestine and it crowds out the good bacteria making proper absorption of nutrients very difficult. These dogs have lots of signs like routine diarrhea, grumbling, growling bowel sounds and just general mal-digestion. Does this sound like anything you have been experiencing? These dogs usually just stick out as having a "bad stomach." The place where these important nutrients is stored is the liver. If the liver is unable to store or the storage is depleted, then the body will eventually be very low in these three nutrients. Again, there is a direct impact to the making of blood in the bone marrow. These nutrients must be there in proper quantity or the cells that are made are fragile. Another very rare problem can be something called a liver shunt. The blood flow that is supposed to go through the liver and pick up these nutrients to put them into general blood circulation bypasses the liver. This is a serious condition and needs special testing to determine. Yes, consistent internal bleeding can also be a cause for these nutrients to be low. This is a very common occurrence in seniors who are on high dose ibuprofen (or other NSAID) treatments for arthritis. This can be an indication there is probably an ulcer (with bleeding). And of course, it leads to low grade anemia. Is your vet a specialist? The testing for iron was very clever, but the diagnostics to get to the cause may be more tricky. The internal bleeding is a good first step, but you can see there are other reasons too. If this were me, I would also start looking at the digestive problems. My dog had an issue like this and I had to give him B12 shots on a regular basis. Some dogs benefit from iron shots as well. I hope owners that are still on this forum will speak up please about this specific iron supplementation if their vet prescribed it, I am not as knowledgeable about this particular diagnosis and treatment. my best patrice

Patrice NYS

Hi Diane, Apologies as cannot offer advice on this, I don't know the technical stuff but am sure others will make sense of it for you. Just hope Mo improves, her body has had a lot to deal with in such a short time. It was months before Archie played as he spent most of the time asleep looking very sorry for himself. Take care, Sue and Archie

Sue and Archie Cambs UK

Many thanks Patrice - the sample is to be taken to the vet tomorrow and so I will make sure the questions are asked! I will let you know what the vet says when we get any results - meanwhile the drugs continue! And thanks so much for the good wishes Sue - Mo is better in herself but no way like her old self. We are trying to be patient in the knowledge that it is a long process. Take care Diane

Diane Milton Keynes

Hi Diane, I know it isn't much help now but we honestly never thought we would have a lively dog in Archie. He was always so laid back and uninterested in any of the toys I bought for him (far too many). With hindsight perhaps he was unwell long before IMHA showed symptoms and as he was only eight months when he had his crisis we will never know. However, in the last few months he has got away with murder as he has entertained us with his discoveries of fun! It may take months before you see the old Mo back, she is very ill and it is an uphill struggle but with your care and support she has the best chances of getting through this. Of course this is also exhausting for you and your family so don't be hard on yourselves, I've got that teashirt and it didn't do me any good. Now just enjoying long walks again and focussing on trying to quieten Archie who barks at everything that passes. Sue

Sue Cambs UK

Diane, I am sorry I don't know the connection between low iron and AIHA, but I don't think it is that uncommon. If it would be, why would so many of us give petinic, a product that supplements iron. This product was not readily available to me, so Dr. Dodds suggested giving iron, B12 and folic acid separately. I don't think it is that easy to just give lots of iron pills to your dog, the body has to be able to absorb it. Don't just go out and give your dog iron pills, discuss it with your vet or contact Dr. Dodds. You can also give too much iron which of course is not a good thing. Patrice mentions digestive problems in her post. I remember we gave Kahlu probiotics, a product called Forti Flora. It is a powder I sprinkled on the food. I don't know if that would help, but worth looking at. If it dos not help it certainly won't harm. Be patient Diane! Try and read some of the success stories. Mo's PCV will go up eventually. Best wishes, Brigitte

Brigitte BC Canada

Hi guys The faeces test came back on Friday and it seems that Mo doesn't have internal bleeding, but she does have some liver damage which was a blow. Apparently, her liver is not functioning as well as it could and so needs some support. Part of the treatment for a poorly liver is steroids but the vet is worried that they are already having an adverse effect on her and wants to reduce her dose asap. So the vet has prescribed two additional drugs, and I would be welcome any advice/guidance as to these, and whether anyone has any knowledge of how long it might take for them to work: Denamarin (225mg of S-Adenosylmethionine and 24 mg of SilybinA+B) - one 1 tablet daily before food Ursodeoxycholic acid (Destolit) - one 150mg tablet daily Needless to say I felt like I had been kicked in the stomach when we received more bad news, but on the plus side Mo's Prednidale has been reduced to a half a 25mg tablet twice daily. And she seems less sluggish on her walks, but more relaxed and more comfortable at rest. This really is a long haul - its only been 5 weeks and it feels like 5 months! Diane

Diane Milton Keynes

Diane, No internal bleeding... You should be jumping for joy! This is great news. I know that the liver damage sounds very serious but you should know that it is very common with AIHA dogs that have been on the medications for a long time. The liver is an amazing organ that is quite capable to heal itself. Having Mo on Denamarin is excellent. Unfortunately it will take some time for the liver values to come down but it usually happens pretty soon after the medications are reduced. You could also ask the vet to add milkthistle to Mo's drug regime. It is a very good herb to support the liver. I have no experience with destolit, from what I have been reading it is prescribed for gall stones. Is Mo on an other immune suppressing drug like azathioprene or cyclosporin? Please don't give up hope! Go back to the Meisha's Hope website and read some of the success stories. It is a long roller coaster ride but Mo can certainly recover and be healthy again! Take it one day at a time. Best wishes, Brigitte

Brigitte BC Canada

Do you have copies of the tests? If not you should ask for them...get them at each visit is the best. *Some Liver Damage*.....I wouldn't mind knowing the numbers to determine the degree of damage there is. Not sure i totally agree with the huge reduction in hte meds but again it would depend on the degree of damage. Denamarin is a great product to use but it IS a highly refined pharmaceutical so it's dose specific. Not sure why they'd add Ursodiol but i've heard it's expensive. Might be worthwhile calling around to other places to check prices. Any words on the other cbc results? My thoughts and prayers are with you both. Johnny & Tessy

Johnny

Diane, I am sorry to hear about the liver issues. If there wasn't liver damage prior to this illness and there has been high dose prednisone prescribed for an extended period, the liver will have some damage, but it will recover once the prednisone is reduced. What is really happening is that the liver is processing the prednisone (one of its jobs) and cells are destroyed doing that. It is attempting to repair that damage and blood tests will show very high levels of ALT, AST and ALKP as cell damage occurs. Meanwhile, the other functions that the liver is responsible for are suffering a bit. The liver produces bile salts that are very important for digestion and absorption of fats and fat-soluble vitamins in the small intestine. Wastes that the body needs to get rid of are also carried along with the bile and eliminated in stool. One of those wastes is bilirubin, this is the coloring that makes red blood cells red. If a lot of RBC are destroyed all at once, the liver can become overwhelmed trying to get rid of all that bilirubin. That is why it is advised to avoid feeding a lot of red meat to a dog that has high liver values. It helps it rest and repair. The liver is also a storage site for iron. If it isn't working well, it will either not store iron well or it will not release it properly. The gall bladder is a smaller organ that stores the bile that the liver makes. When we eat foods with fat, the gall bladder sends that stored bile into a tube that runs into the small intestine so it can help digest the fat. So there are several connections between the liver and the gall bladder and the gall bladder and the small intestine (and the pancreas). Sometimes the gall bladder can begin to develop sludge (oh, yeah it's a medical term, go figure...) and there can also be little stones of bile. There are two kinds of gallstones and I suspect these are the kind that are formed from too much bilirubin in the bile. In humans, if these stones get big enough to block ducts or cause severe pain (or if the sludge blocks good flow of bile), they will remove the gall bladder. Sometimes if it is just sludge, they will try a type of medication that will dissolve these little tiny stones. It can take some time, but sometimes work. The Ursodeoxycholic acid (Destolit) - one 150mg tablet daily is this medicine. It is intended to make these little stones dissolve. They don't usually remove dog's gall bladders. The Denamarin is actually two supplements that are intended to help the liver regenerate cells better and faster. The Sam-e occurs naturally in the body as part of a process. It is well researched in human medicine that supplementing with Sam-e helps heal liver damage. The other ingredient is purified silymarin, the essence of a herb milk thistle. It has also been shown to be very helpful in healing the liver. I used Denamrin extensively when Chance had very very high liver enzyme values. His ALKP was over 8600 (with a normal high value of 212). It worked very well and eventually his values returned to near normal, I believe his ALKP was around 220 for the rest of his life, not a big deal. Again, the liver is self regenerative and can recover from liver damage. You can help right now by feeding a diet that will help the liver rest. Called the liver sparing diet, it consists of some kind of cooked white fish, boiled potatoes or sweet potatoes and veggies like green beans etc. I am sure someone will post a good link for the directions on how to make this. It is not well balanced for the long term, but is very helpful right now to provide essential proteins and carbohydrates. I hope you will relax some and let this medicine work. Mo can sense when you are upset and will respond in kind. Have her see you happy and positive. my best patrice

Patrice NYS

Diane, as usual, Patrice has given excellent advice. She has such a gift of explaining things! here is the link she mentioned: http://www.canine-epilepsy-guardian-angels.com/liver_cleansing_diet.htm Best wishes, Brigitte

Brigitte BC Canada

Hi guys, thanks SOOO much for your positive advice and support. Patrice, many thanks for all of the time you put into explaining Mo's current situation - it really helps understanding the reasons. Mo is up and down in terms of her energy levels - some days she is almost like her old self but others - today for example - she doesn't want to walk very far and her ears are down. She also is fouling the house occasionally which is VERY unusual for her - she didn't even do it when she was a puppy. I have a feeling that might be the drugs, particularly as she also occasionally is sick after eating (this evening). I have bought all of the food required for the liver cleansing diet and so intend to start Mo on this tomorrow. Patrice the links you pointed me to mention Milk Thistle as a good supplement - would you recommend this as well? Brigitte, Johnny and Sue - also thanks for your help, support, prompts and suggestions to ask the vet. They are all really valuable to us. Take care of yourselves and your furry ones. Diand

Diane Milton Keynes

Diane, The Denamarin has the high grade essence of milk thistle (silymarin) in it. So no need to add more. There is generally a great variability in the strengths of different brands of milk thistle. This makes it difficult to dose properly. Stick with the Denamarin for right now. When it isn't as critical to get the liver enzymes down you can switch to a high grade over the counter brand. I am guessing that she may be having some pancreatic pain as well. Remember how the gall bladder is linked to the small intestine and the pancreas? Well, if the gall bladder is irritated, it can also irritate the pancreas and that can be very painful. It can cause inappetence and nausea as well. If she still seems uncomfortable tomorrow hold off on food for a bit until she seems to come to you hungry. Feed her a small amount of easily digestible food like well cooked rice and boiled chicken (or the fish you just bought) with a tablespoon of canned plain pumpkin. Further, if there are digestive problems, she is probably going to have some problems like diarrhea. Don't be angry with her. Can you let her access your basement when you are not available to let her out? Put down a whole bunch of newspapers and see what happens. I hope the canned pumpkin will resolve this, but if it continues, you will need to talk to your vet about treating it. These are the hard tasks, nursing care, that only you can do. And I know you can do this well. Be patient. my best patrice

Patrice NYS

Hi Patrice That is really helpful - thanks so much. I have just ordered some canned Pumpkin off Amazon which will be here in a day or so - you can't buy it off the shelf in the UK. It sounds brilliant so I will make sure we give a little of this to Mo too. She loved the liver cleansing diet food this morning which is great news so I will keep her on this for a while. Luckily we are used to a dog who has diarrhea - our other dog (Powder) has had it on and off all of her life (she has a very intolerant stomach) and so it isn't a big deal for us. We just know that Mo hates doing it - she is a very proud dog! - so we give her lots of love and fuss to make her feel better. I will also give Powder (Pops as she is nicknamed) a spoonful as it may help her too. On the good news front, Mo was very lively this morning wagging her tail and her ears were up which is wonderful to see. I will keep you posted. Thanks so much once again. Diane

Diane Milton Keynes

Hi Diane, I am glad you're getting the advice you need and great to hear that Mo is a little livelier. I hope you can enjoy the weekends sun. I have just got back from my vets with my other dog who is a bit off colour, Archie is totally confused and keeps fetching Jazz toys to encourage her to play to no avail. Role reversal as she used to do this to him. Sue and Archie

Sue and Archie Cambs UK

Ha Ha, that made me laugh. Order pumpkin from Amazon. Here in western New York State you can literally find three different brands of pumpkin on the shelf any time. If this is an issue getting it try using some kind of winter squash similar to pumpkin. The pumpkin thing probably came up on many dog forums years ago because the cans are so easy to find. I don't think there is any special magic about pumpkins except if you are Cinderella and need a ride somewhere....

Patrice NYS

In Canada you get the regular, the organic two sizes and probably 4 different brands! maybe there is a business opportunity:) Our vet said the "magic" is in the fiber, so like Patrice said, any squash would do. The cans are just so handy. Best wishes, Brigitte

Brigitte BC Canada

I just bought some Libbys canned pumpkin from Waitrose !!! I was surprised...but there it was !!

Lola Marlin London

Just make sure that it is plain pumpkin, not pie filling. Brigitte

Brigitte BC Canada

Hi guys, the (Libby's 100% natural) pumpkin arrived this weekend (good old Amazon) and so we will give Mo a little with very meal. She has been on the liver cleansing diet for the last few days, and it might be coincidence but over the last couple of days she has been much livelier - much more like her old self. Still slower than she used to be but she loves having the ball thrown for her on walks and wags her tail madly as she carries it around. She still will only climb the stairs in the morning but we are hoping that that may be the drugs.We have an appointment with the vet tomorrow, and will let you know the outcome. Sue, hope Jazz is ok - I bet Archie is very confused but its lovely that he cares. Hope you are all having the lovely weather we have currently in the UK. Take care.

Diane Milton Keynes

Hi Diane, Just wondered how things have been going for Mo as haven't seen a post for a while? Hope all is as well as can be. Sue

Sue and Archie Cambs UK

Hi Sue Thanks so much for the enquiry about Mo - she is still fighting but it certainly isn't a smooth ride. I haven't been back to the forum for a while - just keeping our head down and fighting. Lots of blood tests in the interim! Mo is a little better in herself but still on heavy duty meds - the vet can't seem to reduce her meds without her pcv falling. She is so good about it all - takes her pills (in chicken!), the sucralfate and the heparin injection (3 times daily!) with equanamity - bless her!. He still thinks there may be internal bleeding, and so is repeating the faetal test tomorrow. Thanks so much for thinking about us - hope all is good with you, and everyone else of course.

Diane MIlton Keynes

Hi Diane, Thanks for replying and I am sorry to hear that the big battle still continues, we were so lucky even though it didn't feel like it at the time. Our prayers go out to Mo and I truly hope you get some indication that things can be sorted soon. Sue

Sue and Archie Cambs UK

Hello new to this site so bear with me please. Found you as I was searching for Destolit tablets (to see if I could get them cheaper than my vets (£62.00 for 60 tablets)>Someone said Amazon but when I tried them they had no such product. Also was interested in the comments about denmarin. My dog is 13ys.and, as you can guess,has liver problems. Any help/advice would be appreciated.

Maggie London

So sorry I haven't been here for a while. I had a long chat with our vet this week, and it seems that where we are (3 months in) is still only the relative start of the process. Given the severity of Mo's symptoms it seems it is likely to be a year or so - does anyone know if this is a timescale that is a usual one? Maggie, it appears that destolit and denamarin are the treatments for liver damage, but Patrice who posts here would be a great help for you on this - I was given great advice. Part of this is a liver cleansing diet - it was developed by Dr Dodds in California but is essentially easy to eat, easy to digest food (potato, green veg and fish). Mo (and her sister Pops) have been on it for a while now and I definitely think it has helped both of them. The vet tested Mo's heparin level (they actually sent a blood sample to the US) and her heparin levels are high which probably accounts for at least some of the internal bleeding, so we have reduced her dosage and its now wait and see. Her pcv is stll at 30 where its plateaued for the last month, and the vet said that it might actually be suppressing her pcv count but it is a fine balance between reducing the drugs and stimulating the pcv count against letting the anaemia resurface. It is such a complex and tricky disease as we are discovering. Keeping our fingers crossed for the next blood test! Take care everyone and the doggies! Diane

Diane Milton Keynes

Diane, Can you give me some insight into the tests that have been done and the results of them? I think there may be something unusual going on with the pancreas, the intestine or the liver that may need more advanced testing by a specialist. But it would be good right now if your vet did a profile test for blood levels of ferritin (iron), B12 (cobalamin) and folate. This won't tell you exactly what the problem is if they are low, but it will tell you why the anemia is not resolving. These nutrients are important building blocks of red blood cells. Does this make sense to you? This can also be diagnosed by examining the CBC for certain red blood cell values that are indicative of some kind of nutritional deficiency. From there you would have to have other tests done (as directed by a specialist) to determine where the fault lies with the deficiencies. If you can, keep a small notebook in the kitchen and track Mo's bathroom habits, diet and any unusual behavior you may notice. Is she prone to diarrhea and gas? Do you ever see large, fluffy stools? Is there mucous? After she eats does she seem disoriented or uncomfortable? Do you notice weight and/or muscle loss? These are important diagnostic clues. This isn't straightforward and will take some detective work on your part. Your vet will be very appreciative of these notes you take. What are some possible treatments? Well if there is something called EPI exocrine pancreatic insufficiency, treatment can involve a special diet and adding digestive enzymes to help digest food better. Many dogs, more than you would think, have something called SIBO, small intestine bacterial overgrowth. Essentially bad bacteria overwhelm good bacteria in the small intestine and compete for nutrients. The good bacteria are not able to help with digestion of food anymore and so nutrients are not absorbed. Treating with a special antibiotic and probiotics helps this. There is a condition of the liver called Portosystemic Shunt where the vessels coming from the small intestine do not connect properly with the liver, but bypass it. Two things happen. The stockpile of iron, for instance, in the liver is depleted and no longer supplies iron to the blood. This would definitely contribute to anemia. The liver also stores energy for the body. In addition, the liver is where the body processes wastes and helps eliminate them out of the body in the feces and kidneys. If this doesn't happen properly, those wastes can continue to circulate in the blood. This is not a good thing. There is no nutritional treatment or medication that can correct a shunt. This should be evaluated for surgical intervention. my best patrice

Patrice NYS

This thread was discussed between 09/04/2011 and 13/06/2011

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