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

Well - We got the call I've been holding my breath about. Winston's doctor got his most recent bloodwork back - his pcv is 30 - down from 32. The bun is down from 57 to 42 - GREAT. Creatinine is normal. However, the ALT is up to 228. She says normal is 100 so he's pretty high. The doctor has recommended we stop Azathiaprine - which he's been getting every other day for some time. I'm really afraid of another slow decline in the pcv. She wants me to increase the milk thistle and stop with the chicken breast mixed into his dinner. I've already stopped with the liver treats when she wanted me to reduce protein in his diet. We don't go back for f/u bloodwork for another 1 1/2 wks. Anyone with any other suggestions on getting the liver value down? I'm not sure how much milk thistle to give so I'm opening the capsule and sprinkling about a third 2x/day.... I've got the pet-tinic ordered Johnny. Thanks for the suggestion.

Lisa TX

Ruger's ALT is 1121!!! Ahhh! I didn't realize it was so high. I guess I didn't know what normal was. We stopped the azzathiaprine but it has remained high. His dr. said it is from the prednisone but we can't lower it till the disease stops. He gets checked again tomorrow so I will ask. Ruger is on Denamarin but I do not know if it is helping yet as he has not been checked since we started it. I will let you know.

jaime parker

Jaime and Lisa, prednizone can make the ALT skyrocket. Why its effects some dogs more than others is a mystery to me. Is Winston still on Prednizone? Wylies ALT shot up to 1000 in only a months time and that was only being on 30 mg a day and she is 55 pounds. It slowly came down as her pred was reduced. Jaime, why did you stop the Azi" Azi? hasn't it been only a few weeks? I am sorry but so many of you are running together I can't remember. Laurie

Laurie CA

Lisa, Have you ever had Winston fully checked for tick born diseases? If not get a FULL tick screen done. There's a big huge test (Patrice would know the name of it) that will check for all of them. The fact that he's regenerative and there's still spherocytes present could say several things....a)something is still triggering the body to attack the blood cells b)the meds aren't quite working (Not enough) amongst others. I'm going to try to find an old protocol that was onthis board and will add it. Check to make sure that EVERYTHING was checked for so you can rule out all causes. Here it is... ~~~~~~~~~~~~~~~~~~~~~~~ Protocol for treating IMHA: (Immune-Mediated Hemolytic Anemia) History: 1. Any history exposure to ticks, any travel to tick infested areas? Other infectious diseases such as leptospirosis, bacterial or fungal or parasitic diseases. Test to rule out Babesia, Ehrlichia, Bartonella, & Rocky Mtn. Spotted Fever, Lyme, as causes. 2. On any current meds that could cause anemia, thrombocytopenia? For example, Sulfatrimethoprim. Estrogens, non steroidal anti-inflammatory drugs? 3 Has there been any exposure to rat poison? Zinc exposure (in the form of coins; seen on X-ray) 4. Were there any recent vaccines (w/in last 3- 45 days? 3. Any concurrent health problems? Neoplasia : Hemagiosarcoma, Sertoli cell tumor, lymphoma. Other conditions: Hypothyroidism, especially autoimmune thyroiditis; Cushing’s disease; Addison’s disease; diabetes; any other recent illness or surgery or stress event including sudden change in temperature? Diagnostics: Minimum data base 1. CBC including platelet count and platelet size (immune-mediated platelets usually have predominantly small platelets). 2. Check Purple Top Tube for auto agglutination, check slide for auto agglutination, look for spherocytes, or stomatocytes on the peripheral blood smear 3. Manual differential, cell morphology (regenerative anemia? (at least 30% of IMHA cases are not regenerative) 4. Spherocytes (near the feather edge don't count) 5. Platelet estimate consistent with low count or due to clumping? 6. Chemistry panel ( Low albumin may indicate hemorrhage) 7. Chest rads & abdominal rads to rule out cancer, pneumonia. 8. Abdominal rads to r/o zinc toxicity (metal coins), cancer, pyometra,etc. 9. Abdominal Ultra Sound to check for Neoplasia(i.e. dog >7yrs) 10. Babesia titer or other infectious diseases if greyhound or if there’s travel history, Ehrlichia, RMSF, Lyme leptospirosis, titer if also thrombocytopenic. 11. UA - look for hemoglobinuria 12. Coagulation panel if evidence of exposure to rodentacides. Or suspected Neoplasia. 13. As the underlying cause can be autoimmune thyroiditis, and thyroxin is needed for normal hematopoiesis, check full thyroid antibody profile. Treatment: (D/C any current meds!) 1. Prednisone 2mg/kg PO BID divided; start at same time as Dex SP is given 2. +/- Azathioprine (Imuran) 2mg/kg PO SID if dog is not responding to the prednisolone. 3. +/- Cyclosporine (Atopica) starting at 10mg/kg SID for the first week, then 5mg/kg thereafter, if patient is refractory to the above drugs. 4. Pepsid–AC to prevent gastric ulcers from the prednisolone. 5. Doxycycline 5 mg/lb bid just in case it is Ehrlichia *Do not use Cytoxin, Oxyglobin - studies show a decreased survival rate with these drugs. 6. Thyroxine (0.1 mg / 12-15 lbs. of optimum weight BID), to stimulate hematopoiesis, or if patient is hypothyroid Transfusions: a. Better to transfuse sooner than later. b. Transfuse if PCV<15% or ( >12% if reduction in PCV is not peracute). c. Use Packed Red Blood Cells (best) or Fresh Whole Blood. d. True universal donor (DEA 4) is best as you usually can't type or cross-match due to auto agglutination. Monitoring: 1. CBC q12hrs, initially, then every few days depending upon the patient affect. 2. Monitor electrolytes q24hrs if on IV fluids 3. Monitor the slide for agglutination q12 - 24hrs 4. Blood smear every few days to look for regeneration, platelets (platelet half-life is 3-5 days; platelet count may not go up because the new platelets go first into the inter endothelial cell spaces to “plug the holes” as seen by fading of bruises or pinpoint hemorrhages and no more new ones; then the next batch circulates and raises the blood count.) Sending home: 1. Prednisone 2mg/kg PO divided BID for at least two weeks, taper very slowly every 10-14 days for another month until platelet count is above 100,000 or PCV is above 21 and stable. Then decrease dose, whenever the blood tests remain stable for two weeks. Eventually the steroids should be given every other day for maintenance. 2. Dogs usually require low dose prednisone every other day for a year or more. 3. Azathioprine 2mg/kg PO SID if needed, then reduce to 1 mg/kg SID, then to 1mg/kg every other day or three times per week. 4. Continue cyclosporine, if needed originally, at 2.5mg/kg SID 5. Continue thyroxin, if needed originally, at 0.1 mg /12-15 lbs. of optimum weight BID, given at least an hour before a meal to ensure absorption. 6. Pepsid-AC PO while on high dose prednisone. 7. Recheck CBC weekly to start; CBC at 1 week, 3 weeks, and then q2 - 3 months while on Azathioprine 8. High protein (35%),low fat diet, no corn, wheat or soy. Split normal amount of food into four servings. 9. Consider Jean Dodd’s “Liver Cleansing Diet” if liver functions are high. 10. Milk Thistle and/or SAM-e for liver health. 11. Pet-Tinic added to food (for iron, B12, folic acid, copper, necessary to form new RBCs). 12. Have plenty of fresh water available for the dog at all times. * Note this was reviewed and edited by Jean Dodds, DVM. Some vets think the thyroid portion is controversial. ~~~~~~~~~~~~~ Also take notice of her liver cleansing diet. This is a very good idea to do! Here's a link to the diet... http://www.canine-epilepsy-guardian-angels.com/liver_diet.htm This site also talks about supplements if you look around. If you look back in the threads to a topic you had on Milk Thistle Patrice had a good explanation on the things that can help hte liver. Hope all this helps. Johnny & Tessy

Johnny

I 2nd Johnnys request to get a FULL tick panel done, its about $200 since you do live in an area of ticks and a high tick disease state as well. I have been reading up in tick diseases recently and even if you had a full panel done right at diagnosis, I read sometimes it can take months for the disease to show up in a test. I think its Karen and Darcy who have been battling it with similar ourtcomes and it was not until she was put on doxyclene was she seeing any improvement. Laurie

Laurie CA

Hi Lisa, Johnny's post is awesome! The biggest concern I have for Winston is why is there still red blood cell destruction and what can your vet recommend to get this under control? Only then will you see the PCV stabilise and hopefully rise into the normal range. Don't be deterred by a drop of 2, these minor fluctuations are normal, and it does not necessarily indicate a downward trend. Were there still spherocytes present in Winston's latest blood work? Is reducing an immune suppressant (Azathioprine in this case) the best way to go if there are still spherocytes present in the blood? Or is it considering another medication regime or increased dosages to stop the RBC destruction? I know it is a balancing act and the liver needs to stay healthy as well.... I don't know the answer, but if this was Millie, I'd want the red blood cell destruction to stop as soon as possible as pretty much my number one priority. Until this happens, our dogs really can't come off immune suppressants, and as such are still vulnerable to all the nasty side effects of these medications. If you can get the destruction under control then the meds can slowly go. I know it's not that easy in practice, I hope that you can get some answers! Keep us posted. Samantha & Millie.

Samantha Geelong Australia

Wow - Johnny thanks so much for the protocal. I put Cod and Pollock on my shopping list! I'm also going to take a copy with me to the doctors office - ask her about the list of possible meds. Winston's last immunization was November 2008. The testing at the time of diagnosis included a check for Ticks and other parasites. I'll ask Winston's doctor if a complete panel can be run again. I've never seen any ticks on either Winston or his sister so I think it unlikely but always possible. His doctor and I have talked about the rat poison possibility as well. There's been a lot of clearing in my area and I think my neighbors were indiscriminate in their efforts to get rid of the rats. I've found several dead and decomposing in my yard - behind shrubbery and near faucets. But Winston's doctor said if he had gotten hold of a poisoned rat he would have died soon after because of hemoraging. It seems possible but since I don't know if there are different kinds of rat poinon out there that have different effects- she might be wrong.... I know there were pesticides that were sprayed into a tree because of ants. That could have dripped onto the ground. Finding the dead rats has been throughout the spring and summer but the tree spraying was in the spring. Could have been 2-3 months before his diagnosis. Samantha - I too am concerned about removing the azathiaprine without adding or changing anything except his diet. I'm scared - If I stop that med this week, that will give him a week and a half off before the next bloodwork. If there's a drop in the pvc will that be attributed to the Azathiaprine or would it happen anyway? If there's a BIG drop - can the downward trend be stopped by adding something back then? or will it be too late... I just don't know. It's like you said - a roller coaster and I'm relying so completely on the judgement of his internist. I'm going to make the liver cleansing food asap. The pet-tinic should be here any day - and I've been giving him Milk Thistle for the last few weeks. I need to evaluate the dose though based on the info in Johnny's link - You all are a wealth of information - I feel so fortunate to have found you here to help Winston and I work through this.

Lisa TX

Lisa, I forgot to mention that this protocol is a couple of years old so you may want to contact Dr. Dodds or send it to her to have her check it over in case she changed anything. It was one I found here in the archives. Remember also that the doses she mentions are large at first but then reduced shortly thereafter.

Johnny

Hi Lisa, Were there any spherocytes in Winston's latest results? Maybe you could hold off on stopping the Azathioprine (I would not be comfortable stopping this cold turkey if it were my Millie), and discuss the protocol posted by Johnny (or the up to date one that he suggested you get from Dr Dodds) with your vet as soon as you have had a chance to get your head around everything? Just a thought.... I agree with you when you say above about the Aza, it could cause a "relapse" if removed too quickly. With nothing else to "replace" it, I don't know how you would get the destruction under control, especially as Winston's PCV hasn't stabilised yet. The question I would ask my vet is "how are we going to stop the red blood cell destruction"? I guess they may need to rule out all underlying causes as a starting point, and go from there. Good luck - I'm confident you and Winston will work this out with your vet, especially armed with Dr Dodds protocol! As always, please keep us updated. Samantha & Millie.

Samantha Geelong Australia

This thread was discussed between 27/01/2010 and 28/01/2010

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