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- Appropriate Cyclosporine Dosage?
Hi Folks! I’m amazed and delighted to have found this website. There is so much to take in when first getting the diagnosis of AIHA; I can use all the help I can get.
My darling 10-year-old pug, Emma, was diagnosed with idiopathic AIHA about two weeks ago. I’m thankful that we caught it relatively early and that she seems to be responding well to treatment. At least I thought she was.
Emma took 10 mg x2 Prednisone and 18 mg generic Plavix daily for the first week after her diagnosis. Her RBC percentage increased from 20-26%. Her appetite miraculously reappeared, she was more alert, and we were thrilled.
Our veterinary internist thought Emma needed an additional medication. She prescribed cyclosporine (50 mg x2 daily) and I’m concerned it’s too high a dose. Emma weighs about 18.5 lbs, and since starting the cyclosporine she seems to have deteriorated a bit. She’s more lethargic (not like when she was first diagnosed, but compared to her behavior last week) and separates herself from the family to rest, which is very uncharacteristic. She’s not sleeping well and her panting has not decreased. She seems uncomfortable, as though her tummy is upset. She’s not vomiting, she’s still eating, and her poop is softer than normal, but otherwise okay.
Is 100 mg/day cyclosporine reasonable? I ask primarily because Emma doesn’t seem to be improving, but also because the vet initially said she’d need 25 mg x 2, but then punched some numbers into a calculator and doubled the dosage.
Emma has a follow-up appt in three days and I can ask the doctor, but I thought I’d see what the experts (you!) thought.
Many thanks!
Hi Marian,
I’m glad you have found our site, welcome! I am so sorry to read about Emma.
We do have a lot of resources here, you can see links to them sliding at the top of the pages. Browse them to read more about AIHA.
Prednisone is the first and most important drug used in the early stages of AIHA IMHA. It can be a life saver in these conditions. While it is very important it does have some difficult side effects that can be seen even as early as a few weeks. I would say that the panting, and in fact most of what you are seeing, is directly related to prednisone.
The prednisone is causing a condition called Iatrogenic Cushings Disease. Iatrogenic means caused by the application of medication. So this is not true Cushings Disease, but has all the signs and symptoms. The condition goes away when the drug is discontinued.
Simply put, prednisone is similar to our own bodies cortisol. This hormone is responsible for adjusting many things in our body in response to stress such as heart and breathing rate, blood flow to organs, sugar levels in the body etc. This is to ensure we have all the resources we need to be ready for “fight or flight.” The levels of cortisol are carefully controlled by our body. But when we flood it with excess amounts of cortisol in the form of prednisone, the body behaves like it is constantly under stress. So to you or me it would feel like we are always in the middle of a car accident, terribly stressed out, breathless, heart pounding.
This is one very good reason Emma is slipping away for some quiet time, the world has suddenly become over stimulating to her. Just let her be, put down folded blankets in front of fans to cool her off, this drug also causes dogs to be hot all the time. She doesn’t feel well and it’s natural for a dog to want to get away.
Other side effects you will see immediately are a lot of peeing, uncontrolled peeing, great thirst, big appetite, shifting of body fat and fluids such that the body begins to look potty. You may see skin infections like staph, hair or coat changes. After a few weeks the liver enzymes will rise as the liver is the organ that processes the prednisone. This causes liver cells to die. The liver will recover from this if there was no organic liver disease prior to this problem. We recommend the use of the supplement Denamarin to help the liver heal quickly from this.
Be careful with fat in the diet right now, pred may encourage pancreatitis which is very painful. Ask your vet to prescribe some form of stomach protection as prednisone will cause stomach ulcers. The most simple of these would be generic pepcid, the basic version, given one tablet a day 30 min before meals. We often suggest you use sucralfate, a kind of mucous “bandage” that protects and heals the stomach from any possible ulcers. Dose this with at least 2 hour on each side of any food or medications.
Aspirin at ultra low doses, 0.5 mg/kg/day PO, is also recommended or Low-molecular-weight heparin (Dalteparin 150 U/kg SC q12h or Enoxaparin 0.8 mg/kg SC q6h) to reduce the risks of inappropriate clotting.
Cyclosporine is often used as an additional drug for two good reasons. The first is that it can take on the job of immunosuppression so that the prednisone can be reduced and those nasty side effects are less. The second reason is that cyclosporine has far fewer side effects than prednisone. And any side effects that it has, tend to disappear immediately after the drug is discontinued (unlike prednisone). It has been researched in dogs for use in canine atopy (doggie allergies) and has shown to be very safe an effective.
When dosing for dogs with allergies, the usual dose is 5mg/kg/day. However Novartis has not drug tested Atopica for use in dogs with more serious conditions like AIHA IMHA. In those conditions, many clinics now start the drug off with a “loading dose.” This dose “kick starts” the body and makes it more effective earlier.
That loading dose, according to Dr. Dodds, is:
For severe cases, other immunosuppressive therapy is given. We much prefer cyclosporine (Neoral,100 mg/ml oral syrup; or Atopica) instead of cyclophosphamide (Cytoxan) and give it at 10 mg/kg for 5 days rest 2 days, then at 5mg/kg for another 5 days. The lower dose is repeated after a 2 day rest on a 5 days on, 2 days off cycle as long as is needed (usually 2-3 courses of 5 days). This drug induces rapid T-cell suppression within about 48 hours and has been safe, effective, and well-tolerated at these doses.”
So you can see that your vet is following this higher starting dose. Atopica is dosed for allergies in dogs between 16-33 lb (8-14.9kg) at 5mg/kg/day or 50mg. But using the 10mg/kg/day dose would double that for a short period of time for the greatest effect. I don’t believe that he will maintain this for a long period of time. Check back with me if he does.
Chance had this higher dose and I can say he had what seemed like psychotic spacey episodes for about an hour after his high dose. He would stare off in the distance during this time and then would be fine later. Because Chance was very very sick, I had no choice but to continue this with him or he was going to die. Within about 3-4 weeks we began to see signs of recovery and we dropped him down to 5m/kg/day.
Most side effects of cyclosporine are gastrointestinal, diarrhea, vomiting, soft poops etc. Over time you may see skin side effects, awful to look at but not generally harmful. A few dogs rarely have more serious side effects, but discontinuing the drug immediately reduces them quickly.
If she continues to have trouble with the cyclo, there are two suggestions that Dr. Dodds has. The first is to give the cyclo with some food for a few days so Emma adjusts to the drug better. This does decrease the absorption (and effectiveness) so it’s important not to dose like this for a long period of time. Or you could also discuss with your vet about lowering the dose temporarily for a few days so she will adjust.
If you are willing to let her adjust without these measures I suggest you get a can of plain pumpkin and add a tbsp a day to her diet. This will help with the soft poops.
Personally, Chance would not have survived if he hadn’t had the cyclosporine. We had three more wonderful years because of this drug. I have also seen many many dogs survive over the past 9 years because their vet used cyclosporine. Dogs that were extremely ill survived.
The side effects of some of these drugs are just awful, like prednisone, and at times they can seem worse than the disease. Rest assured that these are currently the most successful treatments so far at most clinics.
Each clinic may use a slightly different dosage or try different combinations of drugs. But the true work being done to diminish the population of the T-cell lymphocytes are prednisone and cyclo (also immuran). These white blood cells are the rogue elements of the immune system that have lost their original programming and have gone rogue. Until they are tamped down in numbers, they run amok damaging red blood cells.
Please hang on there, you are in the early stages of treatment. We are here to help you through all the complicated decisions you need to make in the next few weeks. We encourage good home nursing care with home made food and we have lots of resources for that. Keep home quiet for now, no visitors, either people or other dogs. She needs lots of rest. If you find she cannot hold her urine, sleep downstairs with her, leash in your hand, to take her out in the middle of the night. I think at this point, I have spent a few months of my life sleeping on the floor or the couch.
my best
patrice
Hi Marian. A welcome from me too.
Patrice has covered it all. Just wanted to add, that yes what you’re seeing is very much the signs of the side effects of the prednisone, so don’t freak.
The fact is, Emma will look most likely worse before she starts to look better.
Do you have a copy of blood test results? If you do, attach them to the Urgent Advice at the top and someone can have a look at them for you and help you understand what’s happening. If you don’t have a copy I’d really encourage you to ask for them every time. It really helps to track their progress.
Stomach protection is very important so be sure to check on that, and the liver enzymes will definitely go up because of the drugs, so liver protection will also be needed I have no doubt.
Bingo always likes to check out the girls so he’s asked that you post a photo of Emma. You can upload a photo by using the Upload Your Photo.
I’d be happy to make up a medicine chart for you too if you like, particularly if you can get the extra drugs for Emma.
Vally and Bingo.
Hello Marian & Emma
A huge welcome from me too. Patrice has explained everything beautifully & I just wanted you to know we have all been through this rollercoaster ride of them getting “worse” before they get better. It helped me a lot to hear everyone else went through this too. They are hot, tired, pant a lot, plus peeing because they drink more water than usual due to the prednisone.
As Patrice said about Chance, my dog would have died for sure without the right treatment Worzel was on a different drug, but it worked afer a few weeks, thankfully) & these drugs save their lives. We get through the side effects as well as we can with the stomach protection & denamarin, plus a good diet high in protein such as fish, chicken, turkey (they can have red meat after the haemolysis stage is over with). It’s best to avoid anything too high fat as this can aggravate the stomach & possibly the liver/pancreas. I also agree that pumkin is brilliant for loose stools – the best thing I’ve found for Worzel.
Please keep us posted on how Emma is doing
All my very best wishes
Sheena (& Worzel & Ollie too!)
Hi Marian! I am so glad you found us! I am sorry you and your sweet pup are going through this disease. I am not a big help with the medical stuff but I am here for support. This disease can send you right over the edge so please feel free to come and vent and share. We love to hear the good things as well as hearing all the bad.
Blessings to you and your pup.
Amy & Coal(diag. @ 4mo with IMHA)
Oh my goodness, everyone! I just saw your responses. I somehow couldn’t find my way back to the website and didn’t receive any notification of your responses.
THANK YOU, THANK YOU, THANK YOU!
A quick update: It’s been a tough road, but Emma is a strong little pug, and we’re doing our best. At the moment, she’s battling a horrible staph infection, and I’m hoping you have experience and advice as to how to handle it.
She’s been on an antibiotic for a week, which seems to have stopped the progression of the infection, but she’s covered with hard, scabby patches that take all the fur off with them when they come off. Have any of you seen this with your dogs? It’s especially hard to see because Emma’s coat was absolutely gorgeous. Truly remarkable. And now the poor pup has bald patches throughout her coat, with more to come.
It feels like a nightmarish game of whack-a-mole. As soon as we get something under control, something else pops up.
So much more to say, but I just wanted to touch base and let you know how much we appreciate the info you provided and your words of support.
Our best,
Marian and Emma
Hi Marian, I’m glad you found your way back to us again.
Unfortunately, it’s not uncommon to see our puppies come down with staph infections.
https://www.secondchanceaihadogs.com/AIHA_Terms/staph-infection/
What antibiotic is Emma on?
You can also use a shampoo which contains chlorhexadine to help as well. Make sure you’re being particularly vigilant about washing your hands, as it can pass to humans.
What drugs is she on now? Has there been any reduction yet? I’m sure you’ll find that as the drugs are reduced, a lot of problems will start to go away. Unfortunately, the drugs are so very necessary, but they do do damage, temporarily.
Vally & Bingo
xxx