Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Ruger Update

Ok. I apologize for the long post but just venting. I have to admit I am not happy with yesterday's results. I know I should be happy as he is stable but I am getting very frustrated. We have spent so much time and money (as I am sure you all have) on fighting this nasty disease but it is still not stopped. I am frustrated because I feel he has no quality of life. He lays around all day. He is hardly interested in his food (he is interested in peopple food but I thought the prednisone was supposed to make him eat everything)and I just hate to see him suffering. He was such a big high strung dog that to see him like this is killing me. My 3 year old asked me yesterday if he would play ball with her again and I couldn't answer...I just started to cry. Here are his results. Maybe I am just not being patient enough. I am going to copy and paste from the vet report. He is going to CSU teaching hospital which is 2 hours from my house because they have the most experience with this in our area. Ruger presented to CSU’s small animal internal medicine service on 1/28/10 for a recheck CBC, reticulocyte count and liver enzymes. He was diagnosed with IMHA on 12/12/09. Today, you feel that he has more energy than he has. He is also eating better and will finish both his breakfast and dinner, but still will not eat his dog food by itself. His left rear leg has also continued to get better, but it is still a little swollen. He is currently on Clavamox, leflunomide, Denamarin, prednisone, aspirin, and Pepcid. On physical exam, Ruger weighed 36.5 kg, which has decreased slightly since his last visit. His body condition score is still around a 3/9, but we are making progress. He still has generalized muscle wasting and icteric gums, sclera (white part of his eyes) and ears. You said that he is starting to have more pink in his ears. His swelling in his left rear leg has decreased significantly, but there still is a small amount of edema in his leg. His left popliteal lymph node (behind his knee) is no longer enlarged. He has a heart murmur due to his PDA but the remainder of the physical exam is within normal limits. Today we drew blood to perform a CBC, reticulocyte count and to evaluate liver enzymes. His PCV is slightly lower at 30% but this is not a significant difference from his last visit. He also has a reticulocyte count that is 206,960. This means that his anemia is regenerative. There were still some spherocytes noted on his CBC, which indicates that his disease is still active at this time. The liver enzymes are still elevated (total bilirubin 2.0, ALP 5740, ALT 1053, AST 128, GGT 407). These are slightly lower than they were one week ago, but relatively the same. This indicates that the increased liver values are most likely due to his prednisone therapy and not to an adverse effect of the azathioprine. Therefore, we have decided to restart the azathioprine (as stated above) to try to get the active disease process at this time. His leg looks like it is healing well, but is still not completely resolved. His CBC also shows an elevated white blood cell count (21.6). Since Ruger is immunosuppressed due to the prednisone and leflunomide, we want Ruger to receive Clavamox until the swelling is completely resolved. That was yesterday so last night I added the azathiaprine back in. This morning he wouldn't eat any dog food. Ate a little chicken. Had diarrhea twice today. Still won't eat much dinner. Got a cup of dog food down him but that is not enough...ughhhh! Dr. said to not give him the azathiaprine tonight and see if that helps. If I don't give it to him will the disease ever stop? How long does it generally take to get stopped? He needs to get off this prednisone so he is strong again!!!!

Jaime Parker

Jaime, Please continue to push forward. I know what you are saying about all of this: the time, the money, and most of all the frustration/fear regarding the quality of life. Ruger needs you to be as strong as you can be and pace yourself. When it gets tough, may you know that all of us who have lost our babies are honestly and truly pulling for you. Try to find more strength, try to find more patience, see the specialists and really discuss your concerns. You can vent all you want to us and we will always listen because not too many other people have a clue about what you are going through. But, when the venting is done, try to get up the next day and fight back. Just my thoughts......may Ruger recover and be the same dog he used to be in time. -Darren

Darren Long Beach

Hi Jaime, I am sorry to hear you are so frustrated - I know when my dogs or cats refuse food, it is extremely frustrating, more so when they are not well. I second Darren - please push forward. You have come so far with Ruger. The early stages of this disease are particularly challening, with many ups and downs. I watched Millie go through the same things as Ruger - lethargy, muscle wasting, tiredness, laboured breathing etc etc. Now I look down at her next to me just over a year after her diagnosis, and she's going crazy mad playing with her sister Mitsy. It's heartbreaking for you right now, but if Ruger pulls through, he WILL play ball with your 3 year old again. My thoughts are I wonder if the Leflunomide is contributing to the appetite supression? I'm quite sure this was mentioned by Patrice and Joanne as a possible side effect of this drug. Maybe check with your vet? I am definitely not a fan of stopping and starting drugs. This will not stabilise Ruger - you are right. Maybe you just need to persist with the Azathioprine and tempt Ruger with food other than dog food. I personally think it's a good idea to introduce Cyclosporine or Azathioprine to Ruger's med regime to try and get the destruction under control. My Millie was on Azathioprine with her Pred, it worked for us, but it doesn't work for everyone. As for the diarrhoea, everyone on here recommends canned pumpkin (not the pie filling). We can't get it here in Australia at our supermarkets, but even pumpkin baby food worked for us as Millie had diarrhoea quite a lot too. I just added a teaspoon in with her food. Please keep us posted, stay positive and Ruger will get well. Samantha & Millie.

Samantha Geelong Australia

Hi Jamie I am sorry that Rutger's is not doing as well as we all hoped he would be doing.. Please ask your vet to try the cyclosporine, if you have not already tried it. The cyclosporine is the only drug that Ginger responded to when she had her second relapse. Once Rutger's is stabilized you reduce the drug, and the cost does come down. Right now Ginger is on 100 mg 1x a day, which cost me about $125.00 a month she is an 75 lb dog and that is the only drug she takes. Our vet feels very comfortable leaving her on this long term as it has very little side effects and many dogs are on it long term for skin issues. Next month if her PCV is good we will reduce it again. It will take a few weeks to work. There are no guarantees with any drug and each dog will respond differently, but I really do think it is worth a try and may save you money in the long run. Sending our prayers your way, Cheryl & Ginger (diag. 9/07)

Cheryl & Ginger Pineville PA

Jaime, I'm going to cut & paste some from you. "Today, you feel that he has more energy than he has." That is a good improvement! "He is also eating better and will finish both his breakfast and dinner, but still will not eat his dog food by itself." That is perfect...it's best to feed him human food at this point anyway due to the increased liver enzymes. Start him on the liver cleansing diet and you'll probably see the liver enzymes drop faster with time! "His left rear leg has also continued to get better, but it is still a little swollen." That is great...you are making progress with this! The antibiotics will help to clear this up. If there are open wounds try cleaning the area with warm water and a mild antibacterial soap then treat the area with a topical cream (not ointment). This will speed the healing process up. "Ruger weighed 36.5 kg, which has decreased slightly since his last visit. His body condition score is still around a 3/9, but we are making progress." This isn't a biggie. Improvement is noted! Tessy lost a few pounds also. Ruger WILL gain this back in the future. "He still has generalized muscle wasting and icteric gums, sclera (white part of his eyes) and ears. You said that he is starting to have more pink in his ears." You doing EVERYTHING right here. Keeping a good eye on these will tell lots. Always use the same lighted area to check these to remain consistent. If you are noticing hte ears getting pinker then they probably are. This is also good news! "His swelling in his left rear leg has decreased significantly, but there still is a small amount of edema in his leg. His left popliteal lymph node (behind his knee) is no longer enlarged." Is this more good news? YUP. Again, the antibiotics will clear this all up. Decreased swelling means things are getting better....not worse! "He has a heart murmur due to his PDA." I'll have to look this one up...not sure what PDA is. Lots of dogs though that deal with this disease has had heart murmers. Hang in there. Time will help this! "His PCV is slightly lower at 30% but this is not a significant difference from his last visit. Hmmm, brings back memories! Tessy was in the exact same boat when she was around the 30% mark. More than likely this means that the body has sort of "leveled out" so to speak. I wouldn't say the PCV is lower.....just stable. Tessy stayed in htis range for over a month and with her there were also still spherocytes present! Like you, I was beyond frustrated! So, what fixed the problem for us? CYCLOSPORINE!!!! Yup, I was very weary of starting more drugs with Tessy but I figured that if I didn't we'ld be stuck at this standstill indefinetely. By adding the cyclosporine, things turned around 180 for us. ALSO, if you were to add Atopica this would mean that you could lower one of the harder drugs (leflu or pred?)! Seriously...look into this. Talk with your doctors. Cyclo is much better for Rugers immune system also. Unlike pred, which suppresses ALL parts of the immune system, cyclo will only suppress the KillerT cells responsible for the destruction! This is slowly becoming the benchmark drug for dealing with htis disease! I kid you not! "He also has a reticulocyte count that is 206,960. This means that his anemia is regenerative." THIS IS SUPER AWESOME!!! The body wants to beat this disease and is doing everything it can to do so. It just needs a little more help. That is GREAT news to hear! "There were still some spherocytes noted on his CBC, which indicates that his disease is still active at this time." Proof that the current meds are not doing the correct job. CYCLOSPORINE OR increase the pred/aza. Cyclo would be easier on hte body though...in my opinion. This is the trick now....how do YOU want to go about stopping htis destruction? We're here to help inany way we can but all we can do is offer advise and support. It's up to YOU and the doctors to decide. "The liver enzymes are still elevated. These are slightly lower than they were one week ago, but relatively the same." Will take some time for the denamarin to start working. Danamarin is a great product for "fixing" and "healing" the liver. Godd call on adding it! There are, however, other things you can do to help these values come down. First, Ruger doesn't like to eat his puppy food...GREAT. This food is probably MUCH MUCH harder on the liver than home cooking. I'd STRONGLY recommend Dr. Dodds liver cleansing diet. It's very easy to do and I bet Ruger will slurp it right up from you! He'll love this I bet. Another thing is you can give his meds with some food. This will also make it easier for his stomach. Just a handfull or so with the meds. I give ALL (except the thyroid meds) Tessy's meds with food. "This indicates that the increased liver values are most likely due to his prednisone therapy and not to an adverse effect of the azathioprine." Not sure if I totally agree with this one. This is off the marvistavet website...."Some patients develop a liver toxicity with azathioprine. This should resolve with discontinuation of the medication but it is important to watch for any signs of nausea, diarrhea, or appetite loss. If these occur, especially in the first few weeks of starting azathioprine, discontinue the medication and notify your veterinarian of these effects." Again....maybe it's time to add cyclo to the mix. "His CBC also shows an elevated white blood cell count (21.6)." That isn't too high. Tessy's is at this point right now alomost (1 year later!). Could mean several things...infections being one of the most likely culprits. Antibiotics will help here maybe. Not a big concern or anything to worry about at this point. "This morning he wouldn't eat any dog food. Ate a little chicken. Had diarrhea twice today. Still won't eat much dinner. Got a cup of dog food down him but that is not enough...ughhhh!" LOL Poor boy! Again....home cook for him if that's what he'll eat. I'd be more than happy to help you figure out something to prepare for him. AND it's not like you have to cook everyday. I cook every 5 days or so for Tessy and refridgerate it in tuppleware. Then I just take it out and put it in the bowl for her. SHE LOVES THIS FOOD...the little stinker! Works wonder for her liver and is loaded full of all the nutrients the body needs to build blood! Again, let me know if you need help here. It really is easy to do...and depending on the food you buy probably close to the same price! "He needs to get off this prednisone so he is strong again!!!" AGREED! However, you can't do this until you get the destruction under control. This is a necessary evil at this point. Again, if you were to add cyclo to the mix then you could lower the pred even faster. "He lays around all day. I just hate to see him suffering. He was such a big high strung dog that to see him like this is killing me." Keep in mind that inmost cases of AIHA/IMHA the dog DOES NOT suffer. They just feel really tired usually is all. That's why you'll see him laying around more. This is good though. It's best to keep a dog calm and relaxed when fighting this disease. Best cure for this....get right in beside him and snuggle with him. Show him what he's fighting for and let him know you're there for him. "I have to admit I am not happy with yesterday's results." HAAA....I just proved to you that YOU SHOULD BE HAPPY WITH THE RESULTS. To me this is all great news. Things are heading in the right direction for you. You just have to take that extra leap now. YEAH YEAH YEAH...I know, I haven't drank coffee now for a month...I've been a bit wired and "chatty" lately. I know this is a long thread and for that I'm sorry. I just want ot help in any way I can. Sometimes the best way to do that is to be precise though. We're here for you remember. Good thoughts and prayers for Ruger as well as some get better vibes. Johnny & Tessy

Johnny

Also, I have a ton of extra drugs that I would be happy to ship to you or anyone else in need including cyclosporine. I kept them to give away (I better NEVER need these drugs to give to my Sugar Bear) so please, please let me know if Ruger needs any of the drugs (I have them all- sound like a drug dealer, huh?) and they were not cheap so I'd love to give them to someone in need. -Darren

Darren Long Beach

Thanks everybody! THANKS JOHNNY! You are right. The results are positive. I have much better spirits this morning and am so ready to fight. When Ruger got this crap I was researching and found the Meisha's Hope page. The first thing I saw was Ruger as one of the success stories and I am convinced he will be...we have a long way to go but we will get there. His PDA heart condition is something he was born with. He always had a heart murmur but not one vet we took him to said it was worth checking out. Come to find out it is a serious condition but one that can easily be fixed, once he is healthy again. It is a surgery where they place a coil in his heart. We are lucky he is alive with a PDA today as many dogs his size don't make it to age 6 with a PDA. Right there we know he is a tough guy and a fighter. I need to take things one step at a time though because he can't have heart surgery while fighting his IMHA! What to do next...Ruger was on the azathiaprine for about a month along with the pred. This hadn't stopped the disease and when his liver values sky rocketed we took him off it and started the leflunomide. (Keep in mind he had this horrible infection in his leg this whole time so I am wondering if it would have worked without the infection going on.) His liver still high and disease still present is why we decided to add the azathiprine back in yesterday. Does anyone think it is worth trying the leflunomide and azathiaprine together even with the diarrhea side effects? I am trying to stay with these 2 drugs because we can't afford the cyclosporine. It is about $500/mnth for him and then his dr. says she has to have additional blood test each week to test the absorption and they are about $100. This = more than my car payment! I am torn because the cyclosporine sounds like the answer but we are out of funds and it is so expensive. My thoughts today are to find a cheaper antibiotic, go to a cheaper liver cleanser and start the cyclosporine...not sure if this is possible but have a call into his dr. Speaking of liver cleanser we did try the liver cleansing diet. The first 2 days he gobbled it up. Then the third day wanted nothing to do with it so I went back to adding chicken and rice to his dog food to get him to eat something. Then he ate chicken for 2 days and was over that. I have tried adding the pumpkin also but he would only eat it for a few days too. Today I added egg to his dog food and he ate that. Apparently he likes variety. Maybe he is just trying to get away with this but with all he is going through I am enabling him to. Any suggestions on other foods to add are appreciated. For those of you that are doing a whole cooked regimen maybe you can help me. I have been adding dog food just to help him keep weight on. When he first got sick he was 40 kilos, now he is down to 36.5 and looks soooo skinny. I don't want him to lose anymore weight and I am not sure how much cooked food a dog his size needs but am totally willing to do it if it will help him and he will like it better. Either way we are not done fighting!!!! Thanks for all the positive thoughts and helping me to have an attitude change!

Jaime Parker

Darren, Drug dealer ha ha! I agree you better never need this with Sugar Bear! I really appreciate it and will take any help we can get at this point. Not sure what all you have but I would love to have Ruger try the cyclosporine. If it cured him I would find a way to keep paying for it. I can mail you $ for the shipping or make a donation to Meisha's hope. You can email me jwitkamp@comcast.net Thanks so much! You all are wonderful!

Jaime Parker

Jaime, I will email you privately for your address. Do not worry about the cost of shipping or anything else. You can repay me by doing your best. I think Kelly may have some extra drugs as well. I have a lot of them so I will ship them all to you so that you won't have to buy any for awhile. The financial aspect of this is one I don't see talked a lot about on this forum because it is really not about that but unfortunately plays a big role. I would HATE to see Ruger not be given every opportunity to succeed and from what I've heard/read, Cyclosporine has the least amount of side effects. -Darren

Darren Long Beach

Darren, I can't thank you enough...tears in my eyes...Ruger thanks you too! Jaime

Jaime Parker

Darren, I don't know if you kept the reciepts and box or not but you can get a rebate for Atopica. Here's a link... www. us.atopica. com/pdf/Atopica_current_rebate.pdf Jaime...here's a couple of other finacial help type sites you could look at....and anybody else for that matter. ... www. imom. org/ www. aahahelpingpets. org/grant_guidelines.html www. uan. org/index.cfm?navid=1 ...remove the spaces for the links to work. Also...if you want to go to cyclo you could always get the generic human version which is MUCH cheaper. It isn't quite as easy on the stomach as the Atopica but does the exact same job for a fraction of the price. Other finacial options....maybe you could talk with the vet clinic you take Ruger to and find out if they can set up some type of payment option for you. Some vets will do this and it will help you greatly. Then you only have to pay a certain amount per month. The diarrhea side effects are common when adding or switching any meds. Usually when adding though. If it persists for some time then changes will have to be made again. YES on the pumpkin! You could also try some probiotics in his food. I use Forti Flora every so often for Tessy. ANY dog really that is taking an antibiotic will benifit by adding a probiotic to their meals. I'll usually give Tessy a teaspoon or two of probiotic yogurt every couple of days but in your case this may aggitate the liver some. Avoid any rich foods for now. Forti Flora (purina I think) is a good option though. I switch up the ingrediants in Tessy's food all the time so that she doesn't get tired of the same ole thing. Let's see, I usually use boiled mashed potatoes, white fish (cod, haddock, pollack, etc), scrambled eggs (keep this quantity low due to liver), string beans or green beans, squash (3 different varieties), spinach, tablespoon pumpkin, boiled lean ground beef, rice, brocolli, beat greens, swisschard, etc. I usually switch up some of these ingrediants...she'll never get all of this in one meal. AND for a dog dealing with liver issues you should split this up into 3 to 5 smaller meals a day. The low fat white fish is an important ingrediant because it contains certain amino acids that help to heal the liver. Hope this info helps. Darren, ditto for Sugar Bear. Nobody wants to have to see this evil disease anymore! Anywho...I'm hungry now from talking about all this yummy food! Johnny & Tessy

Johnny

Hi Jamie How much does Rugers weigh? Ginger weights 75 lbs and she was on 200mg per day, which was her highest dosage and it cost me around $250.00 a month BUT only for 2 months and then we were able to reduce the amount and the cost went down. As far as the blood test for the absorption levels (trough test) Ginger did not have to that done at all since the cyclosporine was working and I don't think it would have to be done weekly. Have you checked on the price of cyclosporine in your area, as I think your vets prices are really high. Check online it is much cheaper then what your vet is quoting. How many mg's of the Cyclosporine is your vet suggesting for Rugers? Cheryl & Ginger

Cheryl & Ginger Pinevile pa

Thanks Ginger. Ruger currently weighs 80 lbs. She wants him on 400mg a day. The price is cheap at the teaching hospital compared to everywhere else I have found but maybe the dose is too high. That is good info. I will talk about this with her. $250/month is doable. $500 a month is getting too steep. Thanks for the info.

Jaime parker

This thread was discussed on 30/01/2010

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