Best Hypoallergenic Diet for AIHA

Drew

Guest

Hello everyone,

Our dog Sophie was diagnosed with AIHA two weeks ago. Sophie is a 11 year old Shih Tzu/Maltese mix. We took her to the vet when she showed extreme lethargy and would not eat or drink much for 3 days. The vet did a complete CBC, which revealed an RBC of 5.04, HTC of 30, and 24.2 WBC. She diagnosed her with an infection and “dizziness,” and gave her an antibiotic, fluids, and pain medication. We called her the next day to let her know that her condition had not improved and she was prescribed a medication to settle her stomach.

Two days later, we decided to get a second opinion, and the second vet, after another CBC, diagnosed her with AIHA. The RBC was 3.19 and HTC 19.1, and WBC 32.4. This vet started her on 10 mg of prednisone, doxycycline hyclate (as an anti-protozoal), and orbax (for any infections).
Since she has been on this trio of medications, she has had her blood checked three more times, with the following numbers:

2 days since diagnosis: RBC 2.41, HTC 16.6, WBC 49, RETIC 316 (no PCV value)
5 days since diagnosis: RBC 2.51, HTC 18.2, WBC 34, RETIC 374, PCV 23, TS 6.0
9 days since diagnosis: RBC 3.59, HTC 27.3, WBC 21.6, RETIC 289, PCV 30, TS 6.2

Since the last visit, the vet has discontinued the doxycycline hyclate and asked us to finish the 20 day supply of orbax. The vet added sucralfate to be given an hour before the prednisone. In a few days, she will only be on 10 mg of prednisone, ½ dose given in 12 hour intervals. Also, the vet has been happy with Sophie’s progress and scheduled the next appointment in 2 weeks time.

About 6 days into treatment on prednisone and the other drugs, Sophie began to act more like herself. We have noticed reduction in muscle, a distended belly, unsteadiness in all four legs (though she is doing better and is able to go on walks at around 60-70% of her usual capacity), increased appetite and thirst.
But she is still weaker and losing muscle mass.

I would very much value your thoughts about what is around the corner that we should anticipate and try to help Sophie. I know there is a lot we cannot control, but the one thing we can control is her diet. What can we feed her during this time that would be helpful to her? Upon her initial diagnosis, the vet asked us to force feed her purina critical nutrition can food. After about 5-6 days on it, she gained weight, and the vet asked us to transition her back to her normal diet, which we did.

Sophie has been relatively healthy over the course of her 11 years of life, but has had chronic ear infections and redness in the eye. Due to these issues, she has been put her on a “hypoallergenic” diet for the last 3 years, which has consisted of Royal Canin Ultamino supplemented with vegetables and fish. She does not have any meat, as our previous vet suspected it was poultry, beef, or pork causing the allergies.

What we have been doing now is feeding her the Royal Canin Ultamino with boiled white fish as a protein source and a variety of boiled vegetables. She has a good appetite and is eating on her own now. We are considering introducing another protein, like bison meat.

We would like to change to a home cooked diet, but are afraid she will not get all the necessary nutrition. Is there a particular supplement she needs while on the prednisone? Would you consider a multi vitamin to support her during this time?

Many thanks in advance.

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Patrice

Keymaster

Hi Drew,
This is excellent news for Sophie!

I am not at all concerned about these values. I have found in many cases after recovery from these conditions that dogs tend to hover a bit lower than their own personal previous normal value. 41.5% HCT PCV and the number of red blood cells at 5.26 are really falling into a normal range. Each lab has a slightly different high/low value for these two things that it’s splitting hairs to think that this is abnormal.

In any case, once a very sick dog begins to recover and reaches values like this, there will be little ups and downs as she gets better. None of this is perfect nor can it follow a perfectly defined tract. So you may see it drop to 38% and then pop up to 42%. This is normal.

For instance let’s look at Chance, my Giant Schnauzer who this site is named for. His final normal HCT or PCV settled in at around 34-36%. But this was perfectly normal for him. We had about a month where it hovered up and down. But for the rest of his life he was at this level, and his body was quite happy with it.

Here’s the secret “sauce.” The real value to watch, and what your vet should be monitoring at this point, is the RETICULOCYTES or Retic on some lab tests. The values come in two “flavors,” the percentage (of the whole) and the absolute value (the number achieved by studying a portion of the sample, counting them and then doing some math to determine the total amount in the blood.) So the textbook value for retics is for a normal person or dog, about 1% of the whole, give or take. The absolute value for normal, ALWAYS in humans and dogs is 60,000 reticulocytes in the blood. This never varies very much.

These retics are the “baby blood cells” made in the bone marrow and sent into circulation. Once in circulation they take about 3-4 days to mature, dropping the RNA inside the cell and then becoming the smaller concave shaped mature RBC. When we look at someone with anemia we count them to define if enough are being made to recover from anemia. As anemia becomes worse (lower PCV HCT), the value of reticulocytes increases (called reticulocytosis the making of blood.) When the anemia begins to subside, the level of reticulocytes drop.

In serious anemia, let’s say 18% HCT PCV, we should be seeing reticulocyte values of upwards of 3-5% and absolute values upwards of 350,000 to even as high as 500,000!

We don’t know what Sophie’s value is but I would sure like to see her most recent CBC because I know what I will probably see, a normal level of reticulocytes.

Think of them as the canary in the coalmine. What you want to watch from now on is NOT the number of RBC or the HCT PCV so much as you want to make sure that there are no steep drops in reticulocytes. This would indicate that the bone marrow is having trouble making RBC, and that is a more serious condition for this group of blood diseases. This is what Chance had, non-regenerative anemia or bone marrow failure.

I am pleased that Sophie is at this point. I have written a complete guide to how to evaluate and slowly decrease prednisone in cases like this. Please go to this page and read it carefully.
https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

Yes you do need to start decreasing the prednisone very slowly, as I have mentioned in this. You are seeing the side effects of the prednisone and they will diminish as you drop the dose. Some side effects may not go away, Chance had a weak back leg that trembled a bit the rest of his life. We go into this disease with one dog and come out with a slightly different version of this dog. They are a bit more fragile and need some extra care but they can live a life of quality.

Sometimes when an owner begins decreasing prednisone, the dog seems worse. Maybe walking slower, starting to get itchy again, their stomach problems come back and they have diarrhea etc. This is actually happening because prednisone is also an excellent drug to reduce inflammatory conditions like arthritis, irritable bowel and allergies. But I would never recommend anyone use it for these purposes for a long period of time.

You may also see extreme fatigue and what appears to be doggy depression, again, this is because of the withdrawal of the prednisone. You should only worry if you see collapsing or inability to walk, these are a veterinary emergency called an Addison’s Crisis. https://www.secondchanceaihadogs.com/AIHA_Terms/addisonian-crisis

Your home care sounds good and yes, I would like to see the Chemical Screen as well to help you monitor the liver values which are probably very high. Both of these documents, the Chem screen and the CBC can be uploaded on this page.
https://www.secondchanceaihadogs.com/urgent-advice

I know it is very very tough to lose trust in a vet. We are often faced with helping owners where we believe the vet may not be helping the dog in the best way possible. We don’t want the owner to lose faith in their vet but we also do not want to see a dog suffer and maybe even die from improper treatment.

I know for sure that prednisone has done it’s job at this point and what we need to see next is how she does with a gradual decrease, yes not more than 25% lower for at least two weeks or longer. Preceded any changes with the minimum blood test PCV, which is very accurate. If you begin to see a slide downwards, take her back in and have her tested with the full CBC, you are looking for the value of reticulocytes to see what is happening.

Any questions?
My best Patrice

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Drew

Guest

Dear Patrice,

First, thank you so much for generosity in starting this forum and for all that you have done to help dogs and their owners. I read Chance’s story, and it gives me hope that with the right care, dogs diagnosed with this condition can survive and have a good quality of life.

Second, thank you for your very generous reply to Sophie’s condition. Your reply post is filled with such helpful and educational information, not only for us but for others who may be going through this same condition. Assuming her values continue to hold until May 13, which is the earliest date our vet wanted to begin the prednisone reduction and which would be about 8 weeks Sophie would have been on 10 mg of prednisone, I will have a conversation with our vet about the 25% reduction schedule instead of the 50%. I am very grateful to our vet thus far, but want to make sure that we are all on the same page concerning the reduction schedule.

I have just uploaded Sophie’s latest cbc to the link you posted. It has both the hematology report from 4/15 and 4/1. Once we can get the liver values, I will upload that report as well. I believe her liver and kidney values were normal according to the cbc done on March 21, the date Sophie was diagnosed with AIHA and the day she started on her current prednisone treatment.

Here are the values from the latest cbc:

From 4/15: RBC 5.26, HTC 41.5, WBC 16.14, RETIC 91, PCV 40, TS 7.0
From 4/1: RBC 3.59, HTC 27.3, WBC 21.6, RETIC 289, PCV 30, TS 6.2

Concerning your question about reticulocytes, her latest values were 1.7% Reticulocytes, 91.0 Reticulocytes and 24.6 Reticulocyte Hemoglobin. On 4/1, they were 8.1% Reticulocytes, 289.4 Reticulocytes, and 25.2 Reticulocyte Hemoglobin.

It appears from these numbers that she is still capable of generating red blood cells.

On the hematology report the only values out of the normal range were the RBC as noted above (5.26), MCV 78.9, Neutrophilis 13.54, Eosinophilis 0.04, and Basophilis 0.33.

Our next scheduled appointment was a month from the last cbc, but yesterday we noticed that Sophie had difficulty urinating. And today, we saw what we suspect is blood in her urine, as it was dark in color and on paper had a pink tint. Last August, she had the same condition (trouble urinating and blood in her urine). I am planning to take her in to the vet the first thing tomorrow morning to treat this. She doesn’t appear to be in pain, still has a good appetite, and her demeanor appears to be the same as it has been for the past few weeks.

I hope it is something that we can treat and isn’t too much of a set back from her improvement thus far.

Thank you.
Drew

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Patrice

Keymaster

Drew,
Thank you for the CBC so quickly!

Yes, Sophie is and has been highly regenerative. Sometimes owners get worried about the values of the reticulocytes, seeing them go way up during recovering and then diminish as the HCT gets higher. This is a good thing. 8.1% is an amazingly high percentage of regeneration. And the companion absolute value 289,000 reticulocytes is a very large number. The Hemoglobin is absolutely normal and this is the most critical reason why I know she if fine, this is the element inside the RBC that carries O2 to the body cells, there is plenty enough here to do the job properly, she doesn’t have anemia which is defined by lack of 02 to the cells.

As I said, once you start seeing about 1% and 60,000 (usually shown as 6k). Think of this, those reticulocytes that generated these values on that test on that particular day were merely a snapshot that particular day. If you had taken another CBC in 3-6 days you would have seen those retics numbers drop and the values of RBC and HCT would have increased significantly as the reticulocytes matured into RBC.

You’ve read above about this a little. Let me explain it in a little more detail. The bone marrow is the location for RBC production. There are precursor cells in the bone marrow, a kind of stem cell or template, that produces all the blood cell types. Hover over the words HSC Hematopoietic Stem Cells to see an image of the types of cells that can be made in the marrow. In reality there are many more steps than I show here, but you can see that these cells differentiate into cells with a wide range of jobs. The lines begin to diverge such that they create a wide variety of cells that the body needs, especially the neutrophils and lymphocytes or white blood cells.

https://www.secondchanceaihadogs.com/AIHA_Terms/hsc-hematopoietic-stem-cells

One of those WBC is called a T-Cell lymphocyte or killer t-cells. They are the part of the immune system that attacks invaders in the body. They first travel to the thymus gland where they are programmed to do this job. But these are also the WBC that go “rogue” in autoimmune diseases like IMHA. They stop recognizing “self” and begin attacking the RBC in this disease. But in other autoimmune diseases they can do other things, so their programming can go haywire for many diseases.

The point of giving immunosuppressives is to suppress the immune system. Prednisone, given in a hemolytic emergency, is a critical drug in the early days. It halts the damage quickly. But long term, the side effects are just dreadful and dogs can become very debilitated. Our goal here on Second Chance has always been to try to help owners keep their dogs as healthy as possible so they can withstand the difficult side effects of drug regimes.

But we also know that now, most clinics are using a secondary immunosuppressive that targets only the T-Cell lymphocytes and simultaneously decreasing the prednisone. That’s how I saved Chance’s life. Many many dogs on this forum have gone this route for treatment and their dogs recovered. Some vets use Imuran or CellCept as alternatives as well. They can be effective but they can also have some serious impact on the bone marrow, possibly leading to bone marrow suppression. Why? Because they are more related to treating cancers than autoimmune conditions and their modus operandi is to destroy rapidly growing cells. That can include the reticulocytes in the bone marrow, thus leading to suppression of these cells.

So right now, I don’t see a good reason to keep Sophie at her previous immunosuppressive dose. She’s clearly having more side effects which weakens her. I would never push for a rapid decrease either, we have seen many times where vets put the dogs on the a 50% decrease and the dogs relapsed. I know Vally agrees with me because she has seen this happen to. THIS IS A VERY DIFFERENT DISEASE AND THE RISKS ARE TOO HIGH FOR RELAPSE WITH A RAPID PREDNISONE DECREASE.

When you begin decreases, do the 25% decrease math so that you are averaging it out over the week. If you end up with an odd value for mg, then give the split dose, with the higher mg in the morning and the lower one in the evening. This mimics how our own bodies prepare cortisol in our own bodies to prepare us to deal with stress during our waking hours.

I am concerned about the blood in the urine. It could be a UTI and she might do well on a specific targeted antibiotic. I see she has a slightly high value for neutrophils which could indicate an infection. So get yourself up early and get a clean first of the day urine catch to bring with you before you get to the vets. Keep it in the fridge until you leave. We can hope it is this simple.

And ask for another PCV, this requires only a little blood and they will view this visually. If they see a drop below 35% then we will know she is attacking her red blood cells again and that would be another reason why she has blood in her urine.

If the kidney is involved you may have to do more tests. But start with the simple first.

I also would like to know if the vet tested for tick diseases and what those results showed. Clearly they gave you doxycycline as a precaution against this, but sometimes it isn’t completely successful if it wasn’t at a high enough dose for long enough time.

The white blood cell numbers are mostly fine. But the high basophils catch my attention, they are very rarely this high. If the eosinophils were also high I might say this is some kind of reaction to a parasite. But that is not the case. There are two other reasons why they could be high. One is an issue in the bone marrow due to cancer and the other is allergies. Perhaps she has had problems with allergies in her life?
my best Patrice

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