Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - Scout update Transfusion 5 and HIG

Hello, everyone. Happy New Year to you all. I'm sorry I haven't posted in a while. Between the holidays, work and the exhausting AIHA battle, I have not had much time. So where were we? My 11 lb (now 10 lb) toy fox terrier Scout was diagnosed on Nov 10. She received packed red cell transfusions on Nov 11, 23, Dec 1, Dec 7(double dose)and Dec 27. She's taking the following meds: Current meds: Prednisone 15mg per day, split into two doses (reduced from 20 on Dec 14) Cyclosporine 50mg per day, split into two doses Pepcid 5 mg, twice per day Aspirin -low dose compounded Thyroxine - .05 twice per day Azathioprine (Imuran) - 10mg per day Reglan 2.5mg twice per day The past three weeks have had us on the typical AIHA rollercoaster ride. It feels like we have two or three good days where Scout is eating, playing, resting normally followed by two really bad days where she is lethargic, absolutely refuses to eat, vomits and has diarrhea. But yet it still feels like, on the bad days, when I give up on her and give in to this horrible disease, she perks up and fights harder. When we last left you, Dr Dodds had recommended putting Scout on Deca Durabolin. The specialist we've be seeing strongly disagreed. I debated the matter with him for some time, but in the end, I went with his recommendation. I must say, it was very difficult and stressful decision, but I do trust him and believe that I have to follow his judgement. That said, I challenge his opinion regularly and am constantly pressing him for more information, more facts, more data. We had Scout on Mycophenelate for several weeks with no real improvement and then added Azathioprine to the mix on Dec 14th. I had my reservations about continuing to pile on meds without reducing or eliminating any and by Dec 21 my poor puppy was so ill that I told the vet that something had to give. He said that I could discontinue the mycophenelate and she immediately seemed better. We had a nice quiet Christmas. Her PCV had fallen very slowly (that in itself feels like a victory) after transfusion #4 on the 7th (33 pcv) to the 27th (17 PCV). The previous transfusions had been lasting less and less time. #3 lasted only 6 days. Although she didn't desperately need another transfusion, we elected to give her another one in conjunction with 4 grams of human immunoglobulin (hIVIg). She left the hospital on the same day with a PCV of 30. I haven't been able to find much on these threads about this treatment. If anyone has any experience with it,I'd be very grateful to hear it. Today, Scout is going in for a pcv and full cbc. I also fear that she may have a UTI, so they will do a sterile urine capture today as well. So far, today seems like a good day. No vomiting and she's eaten some of her usual food!!! Yea!! But the prednisone is taking its toll on her beautiful body. Her muscle tone is gone and she hangs her head when standing. It's heartbreaking. Her spine is becoming visible through the skin. I'm desperately hoping that the imuran kicks in soon and we can drop the pred a bit. She's been on it two weeks, but nothing else has worked so far and it is hard to be optomistic. Sorry for the long post. I'll provide her PCV and CBC results as soon as I have them. Please keep us in your prayers. You are in mine. Dorothy

Dorothy New Jersey

Aw Dorothy....I sure hope things start to work out for you and Scout! It's tough when things go so slowly without improvement. Even tougher if the specialist you're using can be obstinate. SOOOOO glad you stopped the myco....IMO it's a nasty useless drug. There's many other better options out there...cyclo being one. I know very very little on the usage and administration of human immunoglobulin. It's used when other treatments have failed I believe but I'm not totally sure. Read the links on the bottom of Joannes site...http://www.cloudnet.com/~jdickson/treatment.htm This should give you a little more insight. If you can please post the results of the recent CBC as well as the past CBC results to compare to. Refer to the last post you did for the numbers needed. Johnny and Angels Tessy & Sadie

Johnny

Hi Johnny, Thanks for the response. Scout's PCV is 25 today from 30 post transfusion Tuesday. I've tried to map out her CBC results and dates (I think I'm missing one CBC in early Dec). I apologize in advance for any formatting issues. I should have her latest available tomorrow and will post an update. Best regards, Dorothy Date 11/7/2011 11/18/2011 11/22/2011 12/18/2011 RBC 2.98 2.79 2.24 3.8 HCT 20.6 19 15.8 17.1 PLT 277 262 236 560 Retic-abs/% 20,860/.7% 5,580/.2% 26,880/1.2% 7,600/0.2% MCV 69 68 71 45 MCH 24.2 24.7 24.6 17.1 MCHC 35 36.3 34.8 38 WBC 5.6 1.8 16.9 23.8 Neutrophils 41% 64 74 87 Lymphocytes 49% 25 16 11 Eosinophils 1% 1 0 0 Basophils 0% 0 0 0 Bands 0% 0 2% 1% ALK Phos 98 U/L n/a 744 n/a ALT 98 U/L n/a 172 n/a Bun 30 n/a 12 n/a Creatinine 0.6 mg/d n/a 0.6 n/a Albumin 3.2 g/dL n/a 3 n/a Bilirubin 0.2 mg/dL n/a 0.4 n/a Total Protein 6.8 g/dL n/a 6.8 n/a Calcium 9.6 mg/dl n/a 8.8 n/a Phosphorus 4.6 mg/dL n/a 6 n/a Lipase 285 U/L n/a 2244 n/a Amylase 865 U/L n/a 1038 n/a

Dorothy New Jersey

Can you tell me just a couple more things.... -dates of each transfusion ...and if CBC's were done same day were they before or after -the reference ranges for the Lipase and Amylase values -are you using milk thistle

Johnny

Dorothy, I don't have much time today. Yes, there is an indication of an infection. Good to get a sterile culture. There is also a good possibility that there is pancreatitis, painful inflammation of the pancreas. Although Lipase and Amylase values are not perfect for detecting this, when both are high like this it is definitely something to consider as it is a condition that occurs during high dose prednisone use. This must be addressed by the vet, but since we are approaching a holiday you need to be proactive and take some steps on your own. Dogs are very sensitive to this condition. If Scout seems in pain, vomiting, refusing food etc, withhold food and offer only clean water for a day or two. Then prepare food that is very low fat. Fat will activate the pancreas and cause the inflammation to flare again. There is a specific test for pancreatitis in dogs that is very accurate, but right now the Lipase and Amylase values will have to do. my best patrice

Patrice NYS

Hi Johnny, She received packed red cell transfusions on Nov 11, 23, Dec 1, Dec 7(double dose)and Dec 27. The CBC dates don't really correspond to the transfusion dates, but there were none that were done immediately after a transfusion. The reference range for lipase is 200-1800 and amylase is 500-1500. Sorry about the formatting. It looked ok before I hit send... Thanks again and best regards, Dorothy

Dorothy New Jersey

Thanks Patrice! Unfortunately Scout and I have experience with pancreatitis. When she was just a year old, she was hospitalized for 5 days with it after eating a piece (one piece!) of fried calamari that had dropped on the floor. She has been fine ever since, but its definitely a worry now. Last night and today she has been eating and we've had no vomiting since Wednesday. Her bowel movements are also much more normal today. I've found that post every transfusion, she seems to have a couple of bad days, then picks up. I don't know if it is just a coincidence or if its the transfusion. I'll keep a close eye on her this weekend and keep her diet as low in fat as possible. Her specialist works out of one of our major emergency/trauma centers so they are available 24/7 if we need them and only 30 mins away. Thanks, as always, for your advice and support. It means alot to me. More than I can express. Wishing you all peace and happiness in the New Year! Regards, DV

Dorothy New Jersey

I was thinking the same as Patrice regarding potential pancreatitis. Usually if they're out of range and one is double the other then pancreatitis is usually a given. Ask the vet to run a Snap cPL test. This is an in house test. If they can't or don't have this test available then you could send out for a Spec cPL but it's much more pricey cause they'll send it to the lab. If it were me I'd go with my gut and assume there's something going on with the pancreas based both on the above numbers and how she's doing clinically and if she's showing any symptoms Patrice mentioned above. FOR SURE keep her diet fat free and feed smaller more frequent meals. Lots of fresh water. I'd talk to the vet about possibly lowering the azathioprine. According to those numbers the problem seems to be in the production area...the bone marrow. Aza is known to suppress the bone marrow and this isn't something we want right now. I wouldn't stop it totally....maybe drop back to 5mg after the next CBC. I'd also talk to them about lowering the prednisone down to at least 10mg daily. At 1mg per pound it would still be considered an immune suppressing dosage. The higher doses are only used in the beginning to kick start the process. IMO the key drug right now you're using is the cyclosporine. PLUS...if you look at the lymphocyte numbers above you can see that they're properly suppressed now at 11%. Did they give a reasoning behind NOT wanting to try or use Deca Durabolin??? This is something else I'd be researching and questioning them to each time! Let us know todays results. Continued thoughts and prayers, Johnny and Angels Tessy & Sadie

Johnny

I should have said LOW FAT and not FAT FREE above! :)

Johnny

Thanks Johnny. The major objection to deca was that it might stimulate an immune response. Since we did do the bone marrow aspirate, we know that she is capable of and ttrying to produce red cells. Also, he was concerned about the side effects and kidney impairment. I will definitely press him on it next time I see him.

Dorothy New Jersey

many dogs survive a single attack like this. however, they will be more prone to pancreatitis throughout their life. prednisone is driving this and you do not want this to become chronic. dogs do not do well with chronic cases. treat this as a unique single attack now in order to prevent it from reoccurring. p

Patrice NYS

Thank you, both. I will see if I can run her in tomorrow for the snap cpl and will ensure her diet is low fat in the meantime. I have to admit that in my desperation to get her to eat, I haven't been that careful wih her diet, but I will be now. Dorothy

Dorothy New Jersey

This thread was discussed on 30/12/2011

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