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Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - surgery while on Cyclosporine? while in remission?
| Hello all, I have been lurking since my Havanese puppy Jack was diagnosed with non-responsive IMHA in May, at 5.5 months of age. I have found it comforting to read about others' struggles with this challenging disease, and to know we are not alone. My heart has gone out to all who have grieved their pets' suffering. At this point I have a question for those with Cyclosporin experience. We are fortunate that Jack's IMHA is now "in remission". He eventually responded while he was on a combo of Prednisone and Cyclosporine. We are nearly complete with weaning him off the Prednisone, and so far his hematocrit is holding up. His internist strongly encourages us to keep him on Cyclosporine for a total of 6 months from the time he went into remission, to try to minimize the likelihood of a relapse. Meanwhile, in the midst of all this, he has become lame, with a rotated limb deformity due to the growth plate on his left ulna closing too soon, making the other bone of the foreleg, the radius, bow outward and rotate. X-rays show that his elbow and wrist joints are compromised by this condition, and are likely painful (which is why he is choosing to walk on three legs). We have consulted with two orthopedic surgeons about this. Both said they wouldn't do the "big" surgery to straighten out his radius unless/until he is off Cyclosporin and stable in remission. However, one of the surgeons is recommending a smaller surgery to break ("release") the too-short ulna--and she says the sooner the better, regardless of his being on cyclosporine. My questions for folks are: Does anyone have experience with their dog having surgery while on cyclosporine? Any complications (infections, retarded healing, etc)? Do you think the stress of a surgery will trigger a relapse in him? My husband thinks it's not worth risking a relapse; but I hate seeing him limp around, and worry that this will stress and possibly injure his other limbs. We want to do the best thing for him, but it's hard, especially when getting conflicting opinions from docs. Thank you for your input~! Karin Grace |
| Karin Scholz Grace San Francisco |
| Karin, This is a tough question. I had a somewhat similar problem earlier this year. Chance needed a very serious operation of his knee and I was hesitant to have it done because of the anesthesia. He has a heart murmur now and I didn't want to make that worse. He has not been on any pred or cyclo for a long time. I told the surgeon that big dogs need to walk. If he continues to lose his function in that back leg, he won't be able to get outside and do his business. He is too big for me to carry him. So this surgery was very critical. I checked with Dr. Dodds about his past AIHA history and she said she felt there would be no problems with a surgery and in fact felt it was important to do it because he was probably in a lot of pain and that could be very stressful on him. So I did have the surgery done and he survived it ok. Recovery was lengthy and in the middle of the winter, but we did fine. He's walking on that leg well now and I am glad that I had it done. I personally would not have surgery performed on a dog that is taking an immunosuppressive dose of prednisone. However, cyclosporine doesn't impact the whole immune system in the same way that prednisone does. It affects only the "killer t-cells", lymphocytes that are the normal attack cells in the immune system. I've read the product information sheet again just now and many of the side effects of Atopica are dose related. In other words, the higher the dose, the more chance there is for a side effect. There are two significant warnings. One is that it can suppress the immune system enough to leave it open to infections and neoplasia-cancers. The other is that vaccinations given while on Atopica may not be effective and so thus the warning not to give vaccinations to a dog on this drug. The other reported side effects that might impact a surgical patient are that some chemical screen values rose by a small value, but it was a small number of dogs in the clinical trial and there didn't seem to be clinical symptoms associated. If this were me, I would do the surgery. A dog that is lame is in pain. I personally don't see an issue doing surgery on a dog that is on a *low dose* of cyclosporine. But here is what I would do first. I would have a complete workup done. CBC, chem screen, chest and abdomen rads, possibly a SNAP 4DX looking for any tick or heartworm. I would want to know that all body systems are ok. If there are chem screen values that are high, I might hesitate. Next I would talk about the anesthesia that they intend to use. They can pick certain types that are easier on the dog. They should be made aware of the past bleeding history and plans should be made ahead of time to have a proper blood supply ready for any transfusions. Talk about after surgery pain meds and what is the safest plan. Chance had a fentanyl patch for about 4 days. Not every dog can tolerate this. I would also discuss the risk of possible infections and the plan to prevent them and treat any that might occur. He's a young dog and I suspect his teeth are all ok? That's a good thing as well. No bacteria or very little. Make a list of all these points and talk with your internist and surgeon about each one. If you finish the list and feel that most of the questions have been answered to your satisfaction, then consider the surgery. Life is a risk, there are no absolutes. But often a bit of risk brings great rewards. please let us know what you decide to do, my best to you and Jack patrice |
| Patrice NYS |
| I would go with Patrices advise, but do have a question for Patrice. Wow, great info about the cyclo vs the pred Patrice. Karin says Jack is soon to be off his pred but doesn't say when, and wha tthe dose is. Should she wait? When Wylie had her spleen removed my vet did a fast dosing down over 2 weeks since he wanted her off the pred for the surgery. Talk about what type of anesthesia they would use. A splenectomy is a very major surgery and I was amazed at whatever anaethisia they used on WYlie she was awake and moving around that eve and when I picked her up teh next day you would never have known what she just went thru, Laurie |
| Laurie CA |
| Patrice and Laurie, Thank you for your input. I'm glad to hear that Chance and Wylie recovered well after their surgeries! That is encouraging to hear. Jack has recently had all the workup you mention, Patrice, and looks good. SNAP was negative, other tests good. He is on the very last step of his prednisone weaning: .25mg/kg, every other day, for one more week. (He is only 9 lbs, so this is a tiny dose.) The surgeon said this was so little prednisone that she would even do the surgery this week if we wanted to (she feels time is of the essence, since his radius bone is still growing and being bent from the short ulna). She does not feel the Cyclosporin will impede healing or create excessive risk of infection, compared with the need to correct the problem. After meditating on it and reading your replies, I am leaning toward doing the surgery. I do feel he is stable enough to handle it, and that being lame is a big problem for him. Even though I can easily carry this small-fry, dogs are meant to run and play! However, I am troubled that one of the old-timer surgeons feels the ulnar release surgery is "useless" and not worth doing, while the younger surgeon feels it is crucially helpful to reduce the pressure the short ulna is putting on the growing radius bone. This is a different issue than whether to subject a dog with IMHA to surgery--this is a question of whether the surgery is worth doing at all! I think I have a bit more research to do, and another conversation with the surgeon who advocates the ulnar release. Thank you all again! Karin (and Jack) |
| Karin Scholz Grace San Francisco |
This thread was discussed between 05/09/2009 and 06/09/2009
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