Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Need advice please

Ginger went back to the vet again today and her PCV was still at 28. It has been around 28 for the last month despite being on 60mg of pred (now reduced to 40) and 50 mg of Imuran every other day. Her vet took more blood work and is having a CBC w/differential and Reticulocyte cnt t425 and a path Review CBC T331. The predisone is very hard on Ginger and her bones actually make a creaking sound when she walks kind of like bone on bone, the same thing happened and then went away when her predisone was reduced 6 months ago and she has been holding steady in the low 40's until a few weeks ago. I wanted to know if anyone has any ideas if adding Atopica would help, she has never been on this drug, so I am note sure of the side effects. Is this used in addition to the predisone and Imruan? I want to wait until all her blood work comes in and then perhaps also contact Dr. Dodds for her opinion, does anyone have her email address. My vet is going to call me after she gets the blood work with a new treatment plan. But nothing seems to be working. Thanks for your help, Cheryl & Ginger

Cheryl & Ginger Pineville PA

Dr. Dodds can be emailed at hemopet@hotmail.com. You can also go here http://www.itsfortheanimals.com/HEMOPET.HTM for more info about contacting Dr. Dodds. My dog has been on cyclosporine for over 5 years (Atopica is a brand name - it is the same as Neoral, only marketed for pets) because prednisone made her condition worse and she had severe side effects & weight loss on prednisone. We have had no worrisome side effects from it at all. She was initially at 200/mg a day for several months, then 100, then 50, then 25, then back up to 100 for another autoimmune problem. Anyways, she has been at 100/mg day for over 3 years and we will likely not reduce again. There is an increased risk of certain cancers (as there is anytime you suppress the immune system) and many dogs experience some gastro-intestinal problems especially in the beginning. I don't see this as any different from high-dose prednisone or imuran in terms of potential side effects I know there are some who have been on this board that did all 3 at the same time, hope some of them will post. Best of luck in your communications with Dr. Dodds. I have always found her to be very helpful and am lucky to live in So Cal where I have been able to meet her on a couple of occasions.

Ronda So Cal

You are fortunate Ronda that your dog has not suffered any side effects. Choe was on it for 6 months along with pred and experienced really severe pancreatitis on a highish dose (for his size). Problem is with Atopica to check the effacacy you have to send the blood away (not all labs in every state do the test), in my situation it had to be sent to Cornell in NY to see if the count is 'holding' It didn't work for my boy. The numbers always showed low and if we upped the dose he would become severely ill. We finally stopped the Atopica as the vet didn't feel it was helping him. It was a pretty expensive experience. Just wondering, does Dr. Dodds recommend any homeopathic supplements? Jan

jan pa

Cheryl, I'm sorry to hear that Ginger isn't responding as well as she was. Something you said just jumped out at me, and I was going to ask all the other readers a question about. You mentioned that Ginger's bones seem to 'creak' and Tiggs is experiencing some generalized pain lately that the vets and I can't put our finger on...everytime he lays down, or is even gently bumped, he yelps, seems like his whole skeletal system is really hurting. My vet hasn't seen any dogs that have had this type of side effect. It sounds like maybe Ginger is though. I haven't heard anything, just a general hunch that his body is achey for some reason. He is now on 40mgs twice per day, plus the Imuran once daily. Anyone else experience general body pain as a result of the Pred? Keep us posted on your treatment plans and our thoughts are with you! melissa

melissa slc

Cheryl: Sheba, our 11 year old GSD mix, has been on Pred and Atopica since being diagnosed April 3rd. After starting out on 50mg of Pred once per day and 125mg of Atopica twice per day we are down to 10mg Pred and the same dosage (125mg morning and evening) of Atopica daily. (Our last blood work a week ago - PCV of 45 and TS 7.6) We haven't noticed any weird side effects from the Atopica. Most of Sheba's side effects have been related to the Pred (heat intolerance, lethargy, hungry ALL the time!, a little depression now and again, some minor behavioral changes). Sheba has stopped shedding and we are not sure if this is related to the Pred or the Atopica. Also, her allergies haven't been a problem this season. As we continue to reduce her Pred we might start to see some side effects from the Atopica but I'm keeping my fingers crossed. She hasn't been on it long enough for us to really worry about the cancer risk although we do keep it in mind as she had a fibrosarcoma removed from her left shoulder in November 2007. The only "issue" we've had with the Atopica is the timing factor. It has to be taken on an empty stomach so there is a 3 hour time window in the morning and again in the evening where she can't have any food. (We have been known to cheat and give her one or two tiny apple-oatmeal treats - smaller than a dime mind you - after she goes out and does her business.) Sheba is a bit of a treat hound so this has been tough for her. She has learned to tell time though and when I tell her she has 30 minutes before she can eat/have a treat she understands. 5 minutes or so before her "time is up" she comes looking for me! And finally, cost can be a factor for some people. We've been lucky enough to get it from Iowa State's VTH (Sheba was diagnosed there after being referred by our local vet) so it is a little cheaper than it is through online sites. (Our vet does not carry it in the sizes we need so we can't get it through him at the moment.) If you have a veterinary teaching hospital nearby you might see if you can get it through them at a little cheaper rate. Good luck and know that we are keeping you and Ginger in our thoughts and prayers. Rita

Rita IA

Cheryl, I am sorry that Ginger seems to be at a plateau that isn't moving for you. It is time to begin reducing the prednisone and get onto another immunosuppressive drug. This is what Jean told us and is what she will tell you. Cyclosporine (in the veterinary formula Atopica) is a cytotoxic drug that is widely used in vet clinics for dogs with atophy or inhaled allergies. In slightly higher doses it can be very effective in AIHA patients. Cyclosporine was developed many years ago for use in human medicine, specifically for organ transplantation. They found that they needed to suppress the immune system so that it wouldn't destroy the newly implanted organ. The problem with prednisone was that it suppressed all of the immune system and this left the patient susceptible to severe infections. So it was a case of the cure nearly killing the patient. They found that cyclosporine selectively suppresses the T-lymphocytes of the immune system, rather than all of the other cells like B-cells etc. These T-cells are the ones that are most responsible for the damage in autoimmune diseases. Modulating them (when they don't respond to the bodies messages to shut down) is an effective way to keep the immune system under control. It was only a matter of time before it became possible for drug companies to offer Atopica to veterinary use. It hasn't been available more than maybe 8 years at the most? So there have been no studies done to show efficacy in AIHA, only that it is very effective in canine allergies. If you contacted Novartis, they would respond they don't recommend it for use in AIHA for exactly that reason, there are no studies showing it's efficacy and dosage. However, Jean has years of experience with this drug in its human form, cyclosporine. If you understand the science behind this medication, it's not difficult to translate that to canine veterinary use. I can say for sure that it saved Chance's life and I was very lucky to contact Dr. Dodds when I did. It does take some time for it to begin working, I think we went 3 maybe even 4 weeks before we suddenly showed a rapid increase in his reticulocyte counts. Prednisone is well known for many side effects. One of the more annoying ones is the redistribution of fat and fluids in the body. It can be very dehydrating to tissues. It can also rob the body of muscle tissue and replace it with fat. The tissues that comprise the musculature and ligamentous system can dry out and become inflamed. Joints begin to become weakened and looser. This is just one side effect that prednisone has and that is why after a certain period of time it must be reduced slowly. Dr. Dodds can advise you about Atopica dose and the decreasing of the prednisone dose if your vet is unsure of how to proceed. There are no acknowledged resources for this use of Atopica. The main side effect I saw with Chance at the very highest doses was a kind of "spacey" behavior for about 2 hours after the dose. He seemed transfixed and not quite there. As we reduced the dosage that went away. The Novartis Atopica site lists gastro side effects as the most common, things like diarrhea, stomach upset etc. There are known skin changes that can occur in some dogs, a type of crusty growth. You will also see the numbers of lymphocytes decline on the CBC, but this is what you want to have happen! But overall, this drug has much fewer side effects than prednisone. Finally, Dr. Dodds would call this steady PCV of around 28 anemia of "chronic disease." There is a good explanation of that in wikipedia. It falls somewhere between moderate and mild anemia, certainly not dangerous, but obviously very troubling to you and your vet. With moderation in her activity, Ginger can be comfortable at this level, provided it doesn't begin to slide. Let us know what the reticulocyte count is, that will be the most important number from this upcoming test. You will see something like absolute retic or retic %. Absolute should be >60,000 (60k) and the % should be above 1%. If you see <60k, then it might be nonregenerative anemia. I can help you determine the RPI, reticulocyte production index and that will tell you the severity of the anemia as a relationship to the reticulocytes. Sometimes this anemia of chronic disease is really a problem with red blood cell production rather than destruction of red blood cells. It can have a number of causes, for instance malnutrition from malabsorption of important nutrients. It can be related to kidney problems, like infections, because the kidney secretes a hormone that is responsible for stimulating blood cell production. So other testing might be important to look at these factors as well. But the most important thing now is to get that prednisone dose down and get Ginger onto something less damaging to the body. my best to you patrice

Patrice NYS

Every dog responds differently to meds. Dr. Dodds may want to try the Atopica in a specific dose and then increase if Ginger tolerates it well. As I mentioned, Choe became very ill and had to be hospitalized with severe pancreatitis on a 50 mg dose 2X day and we had to decrease to 25 mg. I am always concerned about adding new meds but sometimes you have no choice when improvement is at a standstill.

jan PA

Thank you all so much for your help, I don't know what I would do without this group. No blood test results yet but the vet did call and wants me to reduce her pred to 20 mg a day cutting 10mg off. She mentioned possibly starting the Atopica and checking to see if the generic brand would be okay to use in dogs, has anyone had the generic brand of the Atopica? Do you think it would be in Ginger's best interest if I tell her we want to go with the band name, even though it is more expensive.

Cheryl & Ginger Pineville PA

Cheryl, Somewhere in these archives is a long thread about the generic version of cyclosporine, you may have to hunt for it because it was sometime last year. One person reported that they had been using a generic version and discovered that it was not as effective through their pharmacy. I did some research and found the reports that indicated that. I am short on time today so cannot search for you, but in short, I was very glad that we were using the purest form of cyclosporine in the form of Atopica. It is expensive but Novartis may have some rebates on their website. I know we were able to get a good sized rebate at one time. The alternative would to use the brands that are marketed for humans, but I imagine they are even more expensive. patrice

Patrice NYS

cheryl- my girl SWAY has been somewhere between 16-28% for the last 13 months...so i know how that feels for sure. i dont know about ginger, but with sway...the high doses of meds wasted her body down to nothing, and literally it became just as devastating to her as the actual disease itself. since then we have figured it out, with low doses and just through taking it one day at a time and all. my point is, hopefully they recover fully but if not there is always a chance that they eventually will, and even now, sway is perfectly delightful, we just need to adjust our lives accordingly to be mindful of the things that 'could' slide. luckily, we have only had 1 real scare over the last 9 months wishing ginger luck

josh california

Only two things that I could find quickly... and not the original articles I had found. A more thorough search would yield better results, which I just don't have time for now. Patrice http://www3.interscience.wiley.com/journal/118703816/abstract?CRETRY=1&SRETRY=0 The introduction of cyclosporine (CsA) in clinical practice has significantly improved patient and allograft survival after organ transplantation. The new microemulsion CsA formulation, Neoral, has been associated with a more reproducible absorption and a better patient outcome as compared to the old formulation Sandimmune. Recently, several generic CsA formulations have been tested as bioequivalent to Neoral. Bioequivalence tests have been performed in selected groups of young, healthy male volunteers usually in single-dose studies, and then extended to completely different population, such as transplant recipients. However, growing body of evidence shows that CsA pharmacokinetics in healthy subjects is different from that of transplant patients, treated chronically with CsA. Therefore, converting patients from Neoral to the new generic formulations could be detrimental, exposing patients to increased risk of graft function deterioration and graft loss. Thus, more research and more accurate bioequivalence tests are required to address the unanswered problems dealing with the generic CsA formulations. http://www.doaj.org/doaj?func=abstract&id=253776&q1=Is&f1=all&b1=and&q2=&f2=&recNo=20977 Discussion/Conclusion: In case of the drug cyclosporine, the legal bioequivalence criteria are inadequately. Studies with healthy volunteers and stable renal transplant recipients also evidence relevant differences in bioavailability and therapeutic efficacy between generic formulations and the original drug. A savings potential could not be determined by the use of the cyclosporine generic Cicloral®. In addition, reduced safety and an increased need for monitoring might result in additional costs. The problem will come to a head with the introduction of additional generic cyclosporine formulations, because no legal regulations exist obligating to examine the interchangeability of different generic formulations.

Patrice NYS

I've been using various generics of Neoral (Atopica) for some years now without any problems at all. I have not used generics of Sandimmune, since it is not a microemulsion formula. Neoral (and it's generic equivalents) and Sandimmune (and it's generic equivalents) are not interchangeable. Neoral is a microemulsion, Sandimmune is not The DOAJ link is talking about the diffences between Sandimmune & Cicloral. From the article "Material/Methods: In a prospective pilot study with 12 adult renal transplant recipients the bioavailability of the generic cyclosporine formulation Cicloral® was compared to the original preparation Sandimmun® Optoral during the early postoperative phase." Also, apparently in 2004 or so, there was some problem with pharmacists substituting the non-micro emulsion formulation with the micro emulsion formulation (ie SandImmune generic for Neoral) and possibly vice versa http://www.pharmacytimes.com/issues/articles/2004-07_1312.asp When Gengraf (generic Neoral) was first suggested to me by the pharmacist, I made sure I had done my homework first and quizzed him on whether it would be as effective. I have also used genetic formulations by Eon Labs, SangStat and current IVAX with no apparent loss of effectiveness. Also, I have a personal communication from Novartis somewhere a few years ago, where it confirmed for me that Atopica is the same as Neoral. And, just as Patrice states, since studies have not been done, they do not make a recommendation for Atopica's use for AIHA. I have a lot of data somewhere (way back) regarding the effectiveness of generics and FDA requirements. We all must realize however, that what works for one doesn't always work for everyone. Those of us who have HMOs for our own health insurance are probably well used to the idea of generics and I think, in the majority of cases, they work as well as the brand-name. jmo.

Ronda So Cal

This thread was discussed between 29/07/2008 and 01/08/2008

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