Help and advice – Experience with Acute Respiratory Syndrom in AIHA dog

[Anne]

Hello everyone,

Thanks for sharing your stories and for your support. It made my evening easier. Bilbo was in good spirits tonight, and reading your stories of recovery gave me hope.

I also talked to David to clarify when exactly the medication was changed. He reminded me that the Immuran every other day was changed about 7 days before we diminished the Prednisone, so they wwere not stoppped simultaneously. My mistake, I apologize, it is so hard to keep track of all these medications, and David is the one who handles pill preparation at home. He prepares them ahead of time, so I know exactly what to give and when – I’m stressed out at the idea of mixing any of them up!

So perhaps we should have waited more in between these 2. Now, I only hope that with tomorrow’s results, we’ll be able to reverse this. I’m exhausted and need some sleep, but thanks everyone for your positive energy and all your kind thoughts. It means the world.

[Vally]

Anne-Marie, still too soon in my book. Most of the time there’s a change in anything there’s a good gap to make sure there’s no backward steps – it’s a testing time I guess.

No need to apologise. It is very hard to keep track of everything.

Love Vally & Bingo

[admin]

Hi Anne – Marie

It is possible that Bilbo is losing blood somehow – maybe a GI bleed because of the drugs (I presume your vets are looking carefully for something here?) & this shows the importance of keeping up the tummy protection meds. Sucralfate is very useful for healing ulceration. These drugs are extremely hard on tummies. Or it could be he’s started to destroy his own red cells again – the vets would be able to tell you this by looking at the blood results. Either way, the right treatment will get him stable, so don’t you dare worry too much.

The other suggestion I have is to get a recheck in case there has been an error in the testing. We have seen this a couple of times where a the blood test sample has had a clot in it & the results have been skewed by this. The poor owner had a real fright. A machine is used to count cells & sometimes there can be mistakes because of the sample being left for too long before analysis, for example. Misshandling of the sample is also a possibility – you never know! No-one’s perfect.

If haemolysis is taking place & this is a relapse:- in my experience on here & on a previous site, dogs that are reduced slowly & carefully rarely relapse during drug weaning – I can’t remember anyone who’s gone for the slow option having a problem actually. My opinion is that if the pred is reduced first (25-30% per month ideally) to the smallest dose possible (hopefully that means none at all), then start reducing the other long-acting immuno-suppressants, dogs do better. Sometimes there may be a good clinical reason for a faster reduction (e.g. a bad reaction to a particular drug) but this should be the ONLY reason for rushing things. SLOWLY, SLOWLY, please, please.

Most vets have no experience with this disease and are used to reducing these drugs more quickly because they are often used to treat something entirely different from AIHA/IMHA, maybe a skin condition or other inflammatory disease. AIHA/IMHA is far more serious & you cannot afford to mess around. Weaning protocol is so very important.

Let us know how sweet Bilbo is doing – if he’s comfortable, eating & happy, that is all good news.

Love & cuddles
Sheena, Worzel & Ollie xxxx

[Anne]

Thanks, Vally and Sheena. What worries me is that it seems like the Prednisone was reduced slowly. He started the Prednisone early when he was admitted (I believe it is August 10 or so) and they reduced it on September 4. Going from 25 to 20 seems inside the range you all suggest, so if he cannot even sustain that small a change, right now, does it mean he’ll never be able to?? That’s what worries me right now, and I think that’s why the vet said that such a reaction migt indicate the need for a 4th immunossuppressant, which would be a lot – and that’s whee she hinted at the possibility of letting Bilbo go, which broke my heart.

Also, Bilbo has never been on sufalcrate before, I’m starting it at lunch today, in between meals. His tummy has been sensitve for a while, and he has had diarrhea for he past week, so this should help.

I’m still eagerly waiting for the results. I’ll keep you posted. In the meantime, Bilbo is doing very well, which is a bit puzzling seems he dropped to 21: he eats well, his stare has the small glow he’s known for, he’s resting comfortably. The medication has slowed him down, nos doubt about that, but he doesn’t look depressed to me, as opposed to, say, a week ago. I’ll give him a big hug for you all. :-)

[Anne]

Thanks, Vally and Sheena. What worries me is that it seems like the Prednisone was reduced slowly. He started the Prednisone early when he was admitted (I believe it is August 10 or so) and they reduced it on September 4. Going from 25 to 20 seems inside the range you all suggest, so if he cannot even sustain that small a change, right now, does it mean he’ll never be able to?? That’s what worries me right now, and I think that’s why the vet said that such a reaction migt indicate the need for a 4th immunossuppressant, which would be a lot – and that’s whee she hinted at the possibility of letting Bilbo go, which broke my heart.

Also, Bilbo has never been on sufalcrate before, I’m starting it at lunch today, in between meals. His tummy has been sensitve for a while, and he has had diarrhea for the past week, so this should help.

I’m still eagerly waiting for the results. I’ll keep you posted. In the meantime, Bilbo is doing very well, which is a bit puzzling seems he dropped to 21: he eats well, his stare has the small glow he’s known for, he’s resting comfortably. The medication has slowed him down, nos doubt about that, but he doesn’t look depressed to me, as opposed to, say, a week ago. I’ll give him a big hug for you all. :-)

[Tamara]

Hi Anne-Marie,

I’m so sorry to read of this setback with darling Bilbo. I agree with everyone, the reduction of imuran was much too fast after the reduction of pred, and the reduction of imuran was much too much. Hope’s Steve has had a fairly quick response, similar to Bilbo, and they are weaning very slowly and very carefully, first the pred alone, and Steve is doing very well.

Just wanted to echo that the sucralfate must be given apart from all other meds and meals, ideally 2 hours. This can really complicate the med schedule so let us know if you need help setting up a new schedule.

I want to encourage you to put a lot of weight on how Bilbo is doing, and that small glow. There have been several times now that Ashki has had a drop and it frightened me so much, but it also puzzled me, because he was acting so well and feeling very good. The next time we checked, he popped back up. This just occurred a couple weeks ago again and we all panicked and I was in a horrible state!

Lastly, I really want to encourage you to contact Dr. Dodds. A consultation with her is $100, and you will never pay more, she will continue to help you for as long as you need. She is incredibly knowledgeable and very kind. She understands the way we do :) . This may feel awkward, but perhaps you could say to your vet that you would like get some input from an American hematology and immunology expert, and would she be willing to talk to her? Dr. Dodds will talk to your vet and work with her on Bilbo’s protocol.

I am sending you many hugs and much love. We are with you.

tamara and ashki xoxox

[admin]

Hi Anne-Marie

I couldn’t agree with Tamara more – how Bilbo is acting makes me think things are actually much better than his PCV indicates. How they feel is so important. Do you know, I KNEW when Worzel became regenerative from the way he acted & sure enough, the next test was better! I danced around the room because his PCV went up 4 points! The first “up” we ever had! We did not alter any drug level until he was stable in the normal range for quite a few weeks. Then we reduced the pred only (he had very bad issues with the pred). Then we reduced the azathioprine slowly – this took over a year.

I am still suspicious there could be some sort of test error here, the upset tummy may have a bearing on the drop too or maybe a small bleed has caused this. It’s hard to guess without seeing test results etc. I am hoping his next test will show an improvement to put your mind at rest.

Regarding the pred – no – I don’t think that Bilbo will have to stay on a high dose. I just think this could be a weaning issue. What we are saying is “don’t reduce more than one thing at a time” is always the safest option. I reiterate that I would not want to add another immuno-suppressant personally unless I had this specific instruction from Dr Dodds. She is the only person I trust regarding treatment protocols apart from my Specialist here in France. I do think Tamara’s expert input idea would be a subtle way for you to approach this with your vet. These things can be awkward & I know you don’t want to offend anyone. But at the end of the day, Bilbo is your darling heart & this needs to be done.

There is no way I would even consider letting Worzel go if he was in this situation – they are not suffering any pain, they are just tired. I would seek out the best possible help -that means finding a vet who has vast experience with treating this disease & it’s little foibles. That person is Dr Dodds and I know she will help you.

We are all right beside you through this – have no doubt about that. I know you love Bilbo dearly & I hate to hear you feeling so down about this. We have all experienced highs & lows and it’s no fun at all. Horrible.

Sending big hugs & bisous to you all
Sheena & the boys xxxx

[Tamara]

Anne-Marie — I’m sorry, I just went back and saw that the imuran was decreased first, then the pred. I am wondering how quickly the imuran clears the body; I’m wondering if it takes awhile and that is why the delayed reaction. I know it takes awhile for the imuran to take effect, so it possibly stands to reason that it could take awhile for the reduction to also have a full effect.

Usually weaning and reductions are done every 4 weeks as a rule of thumb — in other words, do a CBC, make the reduction, wait 4 weeks and if all goes well then another reduction. Slowly and carefuly with small reductions.

Hope that helps,
tamara and ashki xoxox