Canine Autoimmune Hemolytic Anemia (AIHA & IMHA) - To Jan Choe's mom/caregiver

Jan, In regard to the following statement you wrote to Sue and Steve: “Just wondering the protocol you used to wean Cassie off the pred. Seems when I get below 2 mg day Choe drops back on his numbers. Jan” If Choe drops back on his numbers when you reduce the pred below 2 mg per day, perhaps it is his way of telling you that he needs to have the dosage of pred above 2mg per day to stay in remission. I know we all want to get our dogs off medications but not all dogs with AIHA/IMHA can be med free. I know of many dogs who are on some low dose of either pred or Imuran to keep them for relapsing. As the source I always quote says “Once the disease is in remission, the dose of prednisone can be lowered by 25% to 35% every three to four weeks until the lowest dose that keeps the disease under control is reached.” It may be that a dosage above 2 mg per day is the dose that keeps Choe’s AIHA under control. At the beginning of Meisha’s illness I hated prednisone because of it’s side effects. But every time we would wean her off of it no matter how slowly, she would relapse. Finally we decided to keep her on 5 mg eod and she was relapse free for many, many years. I came to have a healthy respect for prednisone at that point. Since AIHA/IMHA, at this time cannot be cured, but only managed, many times a low dose of some medication is necessary to keep it managed and that might just be the case for Choe. Have you spoken with your vet about keeping Choe on a pred dose above 2 mg per day? If not that is something the two of you might want to discuss.

Joanne MN

Jan, I was thinking about Choe some more and wondering if you had every gone to an every other day schedule with Choe’s pred? Most sources recommend that so that the adrenal glands will be able to make their own pred like substance called cortisol on the days the pred is not given. If Choe has been on an every day schedule of pred for some time, I think it’s a year or more his adrenal glands might be fooled into thinking that he has no need to make cortisol and that may be why his numbers drop when you go below the 2mg daily dose. This Web site http://www.marvistavet.com/html/prednisone.html says and I quote: “Prednisone/prednisolone are commonly used for several weeks or even months at a time to get a chronic process under control. It is important that the dose be tapered to an every other day schedule once the condition is controlled. The reason for this is that body will perceive these hormones and not produce any of its own. In time, the adrenal glands will atrophy so that when the medication is discontinued, the patient will be unable to respond to any stressful situation. An actual circulatory crisis can result. By using the medication every other day, this allows the body's own adrenal glands to remain active.” Just another thought for whatever it might be worth.

Joanne MN

Hi Joanne, We totally agree with your feedback on the dosage of preds and we were concerned when we stopped Cassies tablets and wondered whether we were getting the right advice from our vet. It was a major worry and we asked Diane (our wonderful vet) whether it was the right thing to do but she was taking advice from specialist consultants at an animal hospital who have dealt with this horrible thing for some time. The only way we will get a clearer picture is when Cassie has her bloods done next week and we will know then if her PCV levels are staying constant. Obviously we want the best for our baby because she has been a little star throughout all this and we will continue to do everything we can to keep her well. If that means going back on the preds again so be it although the side effects are sometimes hard to cope with. The major ones for Cassie were weakness in her legs, depression and the loss of her undercoat. We were so concerned that she would start losing her top coat too but thankfully she didn't and whats more encouraging is that her undercoat appears to be coming back as does her energy. She now leaps about like a demented gazzelle and she is back to her mischievious self. Jan, In answer to your question about her protocol she was originally on 20mg preds twice a day, 100mg ciclosporin, Antepsin liquid twice a day and also aspirin twice a day for 6 weeks. Her preds were then reduced to 20mg per day for 4 weeks. Then she came down to 10mg for a further 4 weeks. Next her Ciclosporin was reduced to 50mg and she was taken off aspirin (Preds stayed the same at 10mg per day) for a further 2 weeks. Next step was to stop the Ciclosporin (preds stayed the same) and that was for a further 2 weeks. Preds then down to 5mg per day for two weeks then 5mg every other day for 2 weeks and then last week we stopped them altogether. Obviously this regime varies according to the advice you receive and we just wait to see if Cassie is going to manage without any medication but like I said earlier her next blood test will be the judge on that one. Incidentally if you would like to see a few pictures of our little star you can see her on Dogster using the following link. http://www.dogster.com/dogs/95721 We continue to wish everyone all our love and thoughts in bringing this thing under control. Steve, Sue & Cassie

Steve & Sue Leicestershire UK

Ah, Cassie is a beautiful girl and the pics are quite lovely. You are fortunate that she seems to be responding so well in a relatively short period of time. My boy Choe (miniature dachshund) developed AIHA in August of 2006 after a second dose in a 6 week period of Frontline. (they recommend a dose every four weeks during flea season). I later learned after a good deal of research that fipronil is a strong, toxic pesticide that is used as a main ingredient and is not properly tested in clinical trials. I am 100% certain the flea control treatment Frontline, manufactured by Merial is severely toxic and life-threateningly dangerous especially to small dogs. I try to tell my story to protect others from using this product. The pharmaceutical companies are strictly in the game for profit. Many, many other pets have also suffered serious adverse reactions from this product. Problem is they (Meril) dares you to prove it...which is extremely difficult. My medical bills to date have been over $10,000 and I have had to take loans to pay the vet fees. But, Choe is my boy. I have been treating Choe for all of this time with meds following four blood transfusions in the early stages of the diagnosis. He very slowly recovered after a terrible nasal fungal infection on top of the AIHA and his RBC/pcv count has increased finally to an out-of-remision state. He was in the 40's for the last few months but suddenly went back down to 38 on the last reading. I had decreased him 1/2 mg pred after every four weeks and he was down to 1.5 mgs day (he is only 13.5 pounds.). I increased him back up to 2 mgs day and that is where he currently stands. I have another reading coming up friday. Joanne....many thanks for thinking of Choe and I. Actually I had been adhereing to a pevious post of yours where you indicate the advised recommendation to reduce 1/2 mg every 4 weeks breaking up the dosage in the am and pm and little by litle weaning to an EOD regimin. I didn't think I was quite at that point as he was still taking the dosages twice a day...but I have shared your post with my consulting vet and I will be anxious to hear her thoughts. Choe looks good energy- wise but his coat is very thin and I atribute that to the pred. It has been a roller coaster ride for a long time. If he needs to be on pred forever so be it, but my preference would be to bring him to the least possible dose. Perhaps the EOD regimin might assist in the situation. thanks again. Jan

jan philly

Jan, One goes to the once a day dosing before going to the every other day dosing. Has your vet suggested to you the once per day dosing.

Joanne MN

Hii Joanne..Choe's pcv readng was up again today to 42, which is great news. Do you think I should decrease him back down again to 1.5 mgs. (with the last reading at 38 from previous 45 I upped him again 1/2 mg). You mentioned the one a day dosing befiore the EOD but I didn't think I was quite able to once a day dose as I was giving him 1 mg in the am and 1/2 in the pm. Didn;t get to wean him down to the dosage so 'low that I could just dose him once a day. What are your thoughts? The vet did not really have a definitive answer for me. She was not sure if it was going to be possible to wean him completely off without him falling out of remission. But she said I could try with (of course) the continual pvc checks. I would like to try.....his coat is so pitifully thin from the pred since he has been on the pred for 18 months and I am very woried about future liver involvement. Jan

Jan philly

Good news about Choe's PCV today. One should not go from giving pred twice per day to giving it eod (every other day). You first need to go to the once per day dosing. I am a bit confused as to what total dose you are giving right now. But if it were me (and this is only based on the cases I have seen and the reading I have done) I would stay on the current TOTAL dose I am giving and give that dose only once per day, in the AM. After 2-3 weeks I would retest again and see what is happening with the PCV. If the PCV is good then I probably would go to an every other day dosing on that same TOTAL dosage and see what happens. By going to the once per day dosing you are giving more time between doses and hopefully casuing the adreanal gland to start to work. I wouldn't even think so far as to whether or not you can completely wean off at this point. Just take it one step at a time and see what happens.

Joanne MN

Jan, That is such great news that Choe's count is back up again, so happy for you! In answer to Joanne's question, didn't you say you were back up to 2mg a day, once in morning and once in evening?? I am a little worried now about Holly after seeing what you said Joanne about not splitting up the dosage. Our internist had told us a while back to issue 5mg only once a day after Holly went 4 days of vomiting. I was unconfortable doing it once a day so I split up twice a day, we are now down to 4mg, but again twice a day, 2 1/2mg in morning and 1 1/2 mg in evening. But now I am questioning myself if I should be giving her all at one time in the morning instead of splitting up to get her adreanal glands also working. We are at 1 year also with Holly this month, (dachshund). Joanne, so your opinion is to only do once a day?? We are only decreaseing 1mg every 4 weeks now, just trying to see if this works in holding her retic count down. He next appointment is not until April 7th after 4 weeks on the 4mg twice a day. Again, Jan, so happy for you and Choe! Linda

Linda Sapphire

At much lower doses, prednisone's function is no longer as an immunosuppressive agent. Or in other words, it's role isn't to suppress the immune system to stop damage to the blood cells anymore. At very low doses, it is indeed meant to coax the adrenal glands, (that have been suppressed in their action from high doses of prednisone) to "wake up" again. Complete withdrawal done too soon is not a good idea, nor is cutting the amount more than 1/3 to 1/4 from previous doses. My vet has advised, and I have read in several places, that prednisone used in this withdrawal dosage should try to mimic as much as possible the regular functions of the adrenal glands. There are two functions of the glands and the one we want to mimic is the one that provides cortisol for stress events. Stress events can be as simple as waking up in the morning and going outside to pee. This may involve some serious fence marking and barking at a few squirrels. <vbg> That is usually followed by a good meal, some routine protection of the house from intruders like the postal clerk and then later a good walk. All these events require cortisol to modulate things like blood pressure, oxygen intake etc, so therefore, morning dosage of prednisone is the best time when you get to a really low dose. Going to an every other day schedule further encourages the adrenals to function. In most cases of high prednisone dosage, they do respond quite nicely when it is gradually removed. The rare instance occurs when they do not respond properly. Anyone at this point should be in contact with their vet *regularly.* While this may seem like the most simple part of the drug withdrawal it is a good time to evaluate the adrenal glands but also functions like the kidneys, heart and liver. We are just about there with Chance and I have a full cbc and chem screen scheduled plus a full vet exam to make sure we are ready to make this jump. I hope I have helped, not confused... Patrice

Patrice NYS

I was attempting to follow this suggestion of weaning (but slower than suggested) via this instruction guide for 'people.' regarding the safe return of adrenal cortex function Does this make sense to you?........... Most patients are told to take the entire day's dose of Prednisone in the morning. But the half-life of prednisone in the bloodstream is only 4 hours. Dividing the daily dose in half and taking one-half in the morning and one-half in the late afternoon (not at bedtime to avoid disrupting sleep) may alleviate some withdrawal symptoms. Weaning from a high dose of prednisone to a moderate dose can be accomplished fairly quickly and safely. If symptoms allow, it is suggested that every two weeks the total daily dose be reduced by half until 20mg per day is reached. At 20mg per day, the body (adrenal cortex) must begin to produce it s own cortisol again and the weaning process needs to go slower to minimize withdrawal symptoms and to avoid dangerous repercussions related to a lack of natural cortisol. Begin your reductions now with the PM dose, keeping the morning dose the same. Ask your doctor for a variety of tablet sizes to facilitate the fractional dosing weaning process. The following schedule should allow for the safe return of adrenal cortex functioning: You are now taking 10mg in the morning and 10mg in the late afternoon. Every 5-7 days, decrease the PM dose by 2.5mg. When the PM dose is zero, divide the morning dose in half again (you will be taking 5mg in the morning and 5mg in the late afternoon) and continue decreasing the PM dose by 2.5mg every 5-7 days until you have reached 5mg per day. When you have reached this milestone of 5mg per day, you must proceed more slowly. At this point you need your own adrenal glands to be producing natural cortisol, as the prednisone tablets no longer are providing enough corticosteroid to keep your body functioning properly. At 5mg per day, it is usually advisable to reduce by only ½ mg at a time, remaining at each new dose level for periods up to a month if symptoms dictate. Take 2.5mg in the morning and 2.5mg in the PM. Decrease the PM dose by ½ mg. every one to four weeks, depending on symptoms. When the PM dose is zero, split the morning dose in half again and continue decreasing the PM dose by ½ mg. as symptoms allow. Repeat the process until you aren't taking any prednisone. If prednisone is decreased too quickly below 15mg per day, the adrenal glands may not begin making their own hormones again fast enough to meet the body's needs, and symptoms of adrenal insufficiency can result. This is especially true if you have taken prednisone for a very long time. Doc can measure the cortisol in your blood to make sure your own body has started to manufacture cortisol again. The

jan philly

Patrice, So I am still confused, I kind of understand what you are saying. So basically the prednisone should be given in the morning and not split when on low dosage like Jan & I are on with Choe & Holly?? I think Jan is on 2mg split and we are on 4mg split. But still confused about the lowering of the dosage. So is lowering 1 mg every 4 weeks okay, you think?? The reason why we are trying this is because when we went down to 2.5 mg from 5 with Holly her retic count started to rise again. So this last decrease of just 1 mg the internist agreed that this was a good choice. However we still have Holly on Imuran daily, and I think Jan just has Choe on the prednisone. Holly's heart, liver and kidney counts have been good, is there a special test for the adrenal glands?? Thanks, Linda

Linda Sapphire

Another note, we are giving HOlly 2.5mg in the morning and 1.5 mg in the evening. Linda

Linda Sapphire

If you go to this article on Corticosteroids http://www.peteducation.com/article.cfm?articleid=1422 and scroll down to the chart you will see prednisone has a duration of action of 12 to 36 hours. The veterinary drug handbook says the same thing and the Textbook of Veterinary Internal Medicine indicates that prednisone has “a biologic half life of 24 to 36 hours” The Textbook of Veterinary Internal Medicine in regard to glucocorticoid (the family of steroids prednisone belongs to) reduction says and I quote: “Once clinical evidence suggests that the condition addressed is controlled (e.g. red cell count normalized when treating immune mediated hemolytic anemia (IMHA), diarrhea resolved when treating inflammatory bowel disease) the dosage of glucocorticoids should be tapered. There is no single, ideal way to conduct this tapering, but certain principles apply. First the clinical condition should be monitored closely. Worsening soon after a dose reduction suggests that the taper is too rapid. Second the severity of the condition holds implications as the rapidity of the taper. Glucocorticoids used to treat life-threatening disease ( e.g. IMHA) should be tapered more slowly then glucocorticoids used to treat other conditions. Third, consolidated dosing with prolonged dosing intervals might spare HPA suppression while maintaining most of the desirable biologic drug effect . For example if administering 5mg of prednisone twice daily, it may be better to first switch to 10 mg once a day rather than simply decreasing the twice daily dose. The daily dose then can be decreased incrementally. Dose interval is changed to EOD (every other day) when the daily dose nears a minimal anti-inflammatory range (0.5 mg/kg for dogs). Often veterinarians choose to increase the dose given on treatment day so the 2 day dose remains unchanged or only slightly decreased initially”. End of quote. Hope this sheds a bit of light on this subject.

Joanne MN

Jan and Linda, Good research on your part to find this schedule! If you go back and look, you will see this is written for humans with specific bacterial infections including sarcoidosis. (http://www.sarcinfo.com/weaning.htm) So the schedule is developed with this condition in mind. These people are still pretty sick and need great care. Hopefully, by the time our dogs reach the point where we can begin decreasing the prednisone, they are going to be relatively healthy. That still doesn't mean that we can decrease the dosage abruptly or without a vet's care. If your vet advises you to use two doses a day, then that is what you should be using. They have the clinical experience to determine what is the best dosing schedule for your dog. I've attached some stuff that is directly written with dogs in mind. Chunking it down into an easier language: Taper the dose so that you can reach an every other day dose. Each dose of prednisone lasts about a day to day and a half. And they probably all would advise doing the decreases according to your own vet's schedule. Most vets have plenty of experience with prednisone, it is given for many other conditions and they are very familiar with how to decrease the doses safely. Yes, there is a test for the adrenal glands called the ACTH test. The dog must be off of prednisone for a week or two. The dog's blood sample is taken, a shot of ACTH is given to stimulate the adrenal glands. An hour later the blood is sampled again and they check to see how well the adrenal glands responded. Another way to monitor the decreases is to have routine chem screens to check the electrolyte levels. A good vet physical exam is also important. They will ask you about symptoms that might occur if the decreases are too severe such as shivering or lethargy. My vet advised me to give Chance one dose daily (2.5mg) in the morning so that is what I have been doing. The Merck Manual lists the biological half life of prednisone as 12-36 hours. We haven't seen any adverse side effects. As soon as we can clear all of the prednisone from his system, I will have him tested with the ACTH test. Patrice http://www.marvistavet.com/html/prednisone.html "Prednisone/prednisolone are commonly used for several weeks or even months at a time to get a chronic process under control. It is important that the dose be tapered to an every other day schedule once the condition is controlled. The reason for this is that body will perceive these hormones and not produce any of its own. In time, the adrenal glands will atrophy so that when the medication is discontinued, the patient will be unable to respond to any stressful situation. An actual circulatory crisis can result. By using the medication every other day, this allows the body's own adrenal glands to remain active." "Prednisone and prednisolone are considered to be intermediate acting steroids, meaning that a dose lasts about a day or a day and a half. After two weeks or more of use, it is important to taper the dose to an every other day schedule so as to keep the body's own cortisone sources able and healthy." http://tinyurl.com/2m9s3v (Merck Manual) "Adverse or toxic effects of glucocorticoids commonly result from the longterm use of supraphysiologic doses to control inflammatory or immunologic disorders. Longterm administration may lead to iatrogenic Cushing’s syndrome, characterized by polyuria, polydipsia, bilaterally symmetric alopecia, increased susceptibility to infection, peripheral myopathy and muscle atrophy, and redistribution of body fat. The gluconeogenic and insulin antagonistic effects of glucocorticoids may precipitate the onset of diabetes mellitus or exacerbate diabetes in animals with existing disease. *Longterm suppression of the HPAA may cause adrenal gland atrophy and resultant iatrogenic secondary hypoadrenocorticism. In affected animals, abrupt discontinuation of glucocorticoid therapy may lead to an Addisonian-like crisis characterized by lethargy, weakness, vomiting, and diarrhea. In severe cases, circulatory shock and death may result."* "The side effects of longterm (>2 wk) glucocorticoid therapy can be diminished using an alternate-day treatment regimen. Once inflammation has been controlled using daily therapy with a drug with intermediate duration of activity (prednisolone or prednisone), a gradual change to alternate-day therapy can be made."

Patrice NYS

When I started lowering Sofie on her Pred, she was initially on 50 mg twice a day. Then she was dropped to 50mg once a day, this dose was done for three weeks. I gave the pills in the morning. After weekly blood draws and seeing her PCV's levels staying in the 50/51 range, her pred was dropped to 25mg once a day for three weeks. Again, the pcv's were tested weekly. After three weeks of this dosage, it was dropped to 25mg every other day for two weeks, then 20mg every other day for one week, then 10mg every other day for one week. Then she was done. She has now been totally med free for two weeks. I am not sure if being a puppy(5 1/2 months at diagnosis)helped her do so well, maybe her organs were not so hurt by all the mediations, but she has not had a set back from day one, and is totally normal. Her next blood test will be in three weeks from now, then 6 months. Her weaning schedule was long, and even though she acted totally normal,and I would have loved to get her off it sooner, I stuck with the schedule and am glad I did because she has had no ill effects nor lasting effects from all the medications.

Joanne Wyoming

This thread was discussed between 26/03/2008 and 13/04/2008

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