Forum Replies Created
Samia,
I have put up a new resource on the website so you can read about the different treatments available for IMHA. It’s very extensive so you don’t have to read the whole thing, but it will give you an idea of how many ways that they can approach treatment.
Got to this page.
https://www.secondchanceaihadogs.com/canine-disease-resources
Below the top picture of a big blue dog there is a smaller picture of the same blue dog with the title “Immune-Mediated Hemolytic Anemia: Treatments for dogs.”
Click on this. It will open in a small window. Click on the up arrow on the upper right to open it in a new tab where you can print and save it.
Any questions, ask.
my best, patrice
Samia,
I am so sorry to read about the difficult time you are having. This must be very stressful for you.
First, I agree with Vally. Given Zoe’s history (she was normal one day and not the next) I am confused why they don’t add cyclosporine to the treatment with prednisone. I believe the Imuran, (a harsh cancer drug), is suppressing the bone marrow.
I can’t tell from your writings if they believe she has stopped destroying her red blood cells yet. They would have done some tests to determine this, looking for types of cells in the blood and monitoring her clotting. Without this information it is difficult to decide if she is actually still destroying RBC or if she has STOPPED making RBC. Do you have copies of any of the tests that have been done on her, I would love to look them over to help you figure this out.
Removing the spleen is a treatment that was once very popular. The spleen is an important organ in the body, and a bit more in dogs. It has various jobs, the main one is to store blood and release it when it is needed for stressful situations. It also is the cleaner of blood, it destroys old worn out RBC and recycles the materials. You see this as the coloring in your urine and stool, it is the iron in the heme molecule inside the RBC. And finally it is a companion organ to assist in immune protection. It monitors the blood elements all the time looking for abnormal things that might be parasites etc and activated the immune system to destroy them.
When a dog develops IMHA, the spleen can be suspicious of the RBC ‘s it is monitoring. It may begin destroying RBC in a mistaken belief that these are the trouble makers. But generally now we understand that there are many other factors that are involved in autoimmunity that lead to the destruction of RBC and the spleen tends to be less of a factor than once thought. Other things should be checked for early in diagnosis and treated as possible. The spleen is the less guilty party here.
So the guidelines about spleen removal are pretty clear that this should only be done if the case becomes intractable. Big word. It means you have tried everything and nothing is working. No response. I am a little uncertain about what they exactly have done to this point but if they haven’t tried cyclosporine, they have not done “everything” possible.
Some of the causes for this to happen to dogs are not directly tangible. That means there is no way to look inside the dog and see everything that is going on. In humans, it is a requirement that doctors must do everything possible to determine what is wrong and they may not give treatments until they have done this and found specific results pointing towards a diagnosis. In veterinary medicine this is not the case. Vets often try treatments that they have been successful with previously and they will develop protocols for the clinic to do these things regularly. They may also use treatments that are not approved for veterinary medicine, but are used “off label” in dogs. For instance in canine heart disease there are many drugs given that have only been tested and approved in humans. They work so they are used.
So the research for spleen removal cautions, don’t do this unless you have looked for everything and treated with everything, including the kitchen sink. Below this paragraph is the statement that most aligns with the thoughts from researchers and vets about splenectomies. Since Zoe has been on immunosuppressive drugs she is at great risk for infections. I just don’t think she could recover well from this surgery and it would be a big job for you to take care of a dog with this large of a surgical suture. She would be very debilitated for several weeks. Can you provide this care while you are getting your own care?
“Consider splenectomy only in patients that have not responded to immunosuppressive medications, that require high-dose and long-term medications to maintain a remission or that are experiencing severe side effects from medications. Because there is an increased risk of developing a number of infections after splenectomy, the surgery is not recommended for patients taking multiple immunosuppressive medications. In addition, before performing the surgery in a stable patient, you will want to be sure to have negative test results for infectious diseases or consider empiric treatment for such diseases first.”
A transfusion would be helpful right now and I urge you to again ask them to take her off the Imuran and put her on cyclosporine (in the US it is a veterinary drug called Atopica.)
Please go to this page on our website and print and save it. (Please use chrome to do this if possible) You can expand the panel with the arrow in the right upper corner to open it to a full tab. There will be ways to print and save in the upper right corner.
https://docs.google.com/viewerng/viewer?url=https://www.secondchanceaihadogs.com/wp-content/uploads/2017/12/IMHA.ITP-by-Jean-Dodds-Updated-Feb-2015.pdf
Read this over. Note #3. For severe cases, other immunosuppressive therapy is given. We much prefer cyclosporin. The dosage is given after this.
Please present this to your vet and suggest that they try this treatment, along with another carefully matched and typed blood transfusion again.
This is the treatment I used to save Chance and one that many of the owners who come here have used to save their dogs.
If you have any test results please use the Urgent Advice page in our menus to upload these tests to me.
Do you have any more questions?
my best patrice
Drew,
My apologies, I know that blood is not in the urine, but rather I should have indicated that the urine can be DARK because bilirubin is being spilled into the urine and even the stool. This happens when there is damage to a very large number of red blood cells at one single time, the debris overloads the kidneys. The hemoglobin molecules from a large number of destroyed red blood cells are being recycled all at once and the bilirubin comes from that molecule (heme). Iron attaches to the heme and that is what colors the blood red. So any dog in hemolysis will probably have dark reddish urine and a rather muddy stool as the kidneys dispose of the heme in the bilirubin. Normally our urine is a bit yellow and that is the same coloring.
I think your vet has done at least one chemical screen during treatment, I would be surprised if they didn’t. That is where all the important values are that tell us the health of the internal organs and other things like the glucose, electrolytes, albumin and other important values. A full panel is expensive but at least one chem screen should be done to make sure that internally the dog is remaining stable. We call this homeostasis, the dog is managing to control a perfect internal balance despite being ill. A lot of dogs with IMHA and bone marrow failure are actually quite healthy otherwise! There is great hope for these dogs to recover if done correctly.
So the kidneys and liver are important to monitor during this kind of treatment because of the use of prednisone (which must be metabolized by one or the other organ.) The liver enzymes (indicating cellular damage) will go up because of prednisone, there is no getting around this, but once the prednisone is removed the liver is a highly regenerative organ and can recover. My vet is able to break out just a few of these markers from the full chem screen by doing something called a mini chem. Usually includes liver and kidney among a few others. I’ve done this many many times. Less expensive.
Yes you can do the PCV to monitor her at this point. Make sure you request a “technician visit only” to draw the blood and a SPUN PCV. They know how to do this, they are all trained. Always be polite but get what you want done. This is your dog and your money. I would expect any vet treating a dog with this severe of a condition to help the owner by suggesting ways to reduce the costs. Be sure that she is fasted for at least 8-10 hours prior to all blood draws. Lipids in the blood from a recent meal will alter the results and show aberrant readings. On this PCV test, that would show up as a layer of fatty material at the top of the spun tube.
Simplicef is specific for several staph strains and e. coli so is probably covering both the skin and UTI fairly well.
Your experience with the previous vet is shocking. We have seen some clueless vets treating dogs here and it never ceases to amaze me how out of step they are with this condition. That’s the hard part of what we do here, sort out the treatments that are not necessary and point towards the treatments that have become standard and expected.
Again, our goal is to help owners keep their dogs as healthy as possible while they are in treatment and make that treatment as short and successful as possible. In the first 24 hours, the most important diagnosis should be done. There should be a checklist of steps to follow and standardized testing, followed by immediate appropriate treatment. Any dog presenting as yours should be given a CBC immediately and subsequently put on dexamethasone and kept for 24 hours to monitor.
Well, we don’t know, and more specifically I don’t know, how well Sophie can handle this decrease. So our guidance is always from the standpoint that dogs are not equivalent in their health after months of treatment with prednisone. Some dogs may have a very easy time, others won’t. The risk is simple, a dog that has trouble recovering their own cortisol production is going to have a very hard time with the loss of prednisone on a daily basis. Try to compromise with your vet about this. What harm would there be to do a week’s worth of 25% reduction, just to see how she handles it?
With Chance’s treatment I had a very good idea what I was doing. I have a medical background and when he was very sick I bought and studied a veterinary hematology textbook. I worked with Dr. Dodds often by email and studied constantly. My vets were my clinical advisors and answered all of my questions. I have never stopped studying this condition. Luckily now there is more valid research and information on the internet about all these blood conditions. I was treating Chance in 2007-2008. There was nothing on his condition, bone marrow failure. Dr. Dodds was my source for everything on this. I learned so much. In fact it wasn’t until the last 5 years I began to find research and treatment protocols like Dr. Dodds’ on the internet and it confirmed that what I thought had happened to him, from my studying, was actually what DID happen to him.
So vets need to stay on top of this kind of condition. But many clinics may only see this once in a while, and honestly they probably don’t read the information now available. They get irritable with owners who “internet” them constantly. They resent being challenged because they think that the owner is reading nonsense.
You’ve done a great job and I hope you will be seeing some real improvement very soon, as you have mentioned that she seems perkier! That is the sign we look for, despite the test results, is your dog acting like they feel better? If so, then they are probably better!
my best, Patrice
Hi Drew,
Let’s do the easy stuff first. Of course CBC’s are very expensive. They are not necessary to be done frequently. That’s why the PCV is such a good substitute. You can see a picture of this on this page.
https://www.secondchanceaihadogs.com/AIHA_Terms/pcv-packed-cell-volume
A PCV is packed cell volume. It requires a tiny amount of drawn blood that is put in a small tube and spun. When that’s done you see the “white” stuff (serum and WBC) at the top and the “red” stuff (RBC, Platelets) at the bottom of the tube. They hold that up to a chart on the wall and can tell in an instant what the PCV percentage is. This is actually the more accurate way to determine what you think of as Hematocrit or HCT. In fact all the dogs we see here that are recovering I highly recommend this over the HCT
This little bit of blood can be drawn by a tech, spun and the results known in about 10 min. It shouldn’t cost much at all and that is why I recommended it to you. You don’t need to see the vet. My vet charges me about $15 for the tech visit and the PCV shouldn’t cost more than $15. If they do, they are taking advantage of you. Vally what did you pay in Australia?
So most vets use an automated analyzer to test the blood sample. They take a blood sample and then put that on a slide which goes into the unit. Our dogs here on this forum are very sick and they have a lot of unusual cell types in their blood because of their illness. The analyzer can often make mistakes about what it thinks it is seeing in these dogs. This leads to inaccuracies.
All dogs on prednisone are also very dehydrated so the “make up” of the blood sample tends to have less fluid in it and that means some blood elements seem overly represented on the test. I’ve seen plenty of tests where the dog was dehydrated and it appeared that they had really high platelets. On other tests the report said there was “clotting on the feather edge” and the platelet levels would be artificially way too low! Neither was an accurate reading of the dog’s platelet value.
It’s way too critical to know exactly what that PCV is because medication dosage decisions are being based on that value. That I why I always recommend either the PCV only if the owner has reduced funds or both that an the automated analyzer if they want a more accurate HCT PCV level.
The history of this goes way back to the first world war. The PCV was the only way to evaluate blood. Up until the 1980’s most medical students were taught how to do this as it remains a standard of care.
The main reason for Sophie not to do this rapid decrease is her age and the response I expect is going to happen if she suddenly has half the dose of prednisone removed . We’ve touched on this briefly in the Prednisone Reduction Guidelines link I posted for you.
When we flood the body with prednisone in high doses we are really overloading the dog’s system with what mirrors their own cortisol. The body very carefully monitors this level because it is a critical to our metabolism and many other things like our heart rate, breathing etc. That is why cortisol is related to the “fight or flight” reaction in our body. Cortisol helps us handle stress by activating the appropriate systems to rev up and deal with stress.
When you are almost in a car accident you feel almost woozy and over stimulated to the point that you can’t focus on the details of what just happened.
So the adrenal glands produce cortisol. They do it in response to the many systems I referred to above. When you dose prednisone at very high doses the adrenal glands respond to the flood of cortisol and shut down, not needed. They actually shrink during this period of time. If you suddenly withdraw 50% of the cortisol (prednisone) from the body, the glands are unable to respond to stress properly and can’t provide cortisol, they were asleep and it’s going to take time, in weeks or months, for them to get back to doing this properly.
Dogs live their life on the edge of high stress all the time, everything in their day is either drowsy, sleep or alertness. For a dog the doorbell ringing is the same stimulus as a car accident is to us. They were made this way so they can survive! Dogs haven’t really evolved away from this yet.
So we drop Sophie’s prednisone in half. Let’s say she has this moment of fight or flight, door bell and barking, whatever. He body is going to want to move blood from the extremities to the heart, breathing and heart rate go up very quickly, every system in her body goes into alert mode. But the cortisol isn’t there to do this. She is still going to respond to her instincts to be excited and she is going to collapse. This is an Addisonian Crisis, caused by the administration of prednisone (not a tumor.)
At the minimum she is going to feel terrible for weeks. I’ve reduced prednisone in my own body and I can tell you I felt like dying. It’s not an easy drug to reduce. Many human doctors do reduce like this, 50% right off and then a more gradual rate after. I hated it. But these dogs here are very debilitated, they have been very sick from an illness and the side effects of the drugs. This is a shock to their system.
What if the triggers that started the IMHA are still in her environment or were suppressed in her body all this time and we reduce the prednisone too quickly? She may relapse and we have seen that a number of times, not only in the visitor’s dogs to our website but many of the owners who donated their time to this forum at one time also had this happen. Some of those dogs died from a relapse.
Why did I want to see another PCV right now? I wanted to make sure that this rapid regeneration of red blood cells was not due to some kind of internal bleeding or a relapse of the IMHA destroying red blood cells.
Regeneration is a very good thing to see on blood tests. We love to watch those RBC, HCT and Hemoglobin values rise. But in some cases we see very high regenerative rates because it is a response to continued massive hemolysis (destruction) of red blood cells in circulation.
Here is how I have explained this for years. Imagine you have glass and you want to fill it with water. You go to the tap and fill it up. You set it aside and over a few weeks you notice that some of the water has evaporated. You go to the tap and refill the little bit of water that evaporated. All good. This is how our body normally works, we make blood and we top it off a little bit every day as or old RBC get worn out and are destroyed and new RBC are made.
But lets say there is a small hole in the glass. You fill it up but it leaks a little every day. When you look at it you see it needs more than just topping it off, it’s half empty. That’s a dog with IMHA that is moderate or a dog that has bone marrow failure.
What if there is a huge hole in the bottom. You take the glass to the tap and start to fill it but you can never get it to stay full for more than a few seconds. This is a rapid out of control hemolysis of red blood cells in the body. The bone marrow responds rapidly but you never see the enough red blood cells to replace the ones lost.
So this is an important time right now to make sure that those high values of reticulocytes were actually turning into new RBC and they are indeed hanging around permanently. That’s what I wanted to see with the PCV. If today there was a significant drop, let’s say to 30%, that means there is still hemolysis. The blood in the urine was the key to my thoughts. Many dogs will spill red or orange into their urine when they are in hemolysis. So I was just being cautious for your sake.
Basophils could be high due to the bone marrow but this is quite high. We’ll have to see what is on the next test after the antibiotics are working. What drug did they give you and what was the dose?
No I don’t like the decreases. If this were me I would decrease 25% averaged out over the week. Multiply the dose in milligrams by the number of doses per week. Take 75% of this value. That will be the dose over the week. Now divide by the number of days. Round up to an even number so you are staying on the higher side and also to accommodate how well you can break up the pills to accomplish this, never round down. Monitor her behavior very carefully to make sure she is not experiencing any negative side effects like stumbling, collapsing, not eating, difficulty breathing etc.
At 3 weeks do a PCV (remember this should be a tech visit only and a tiny bit of blood). If it is holding close to 38-40% then begin another reduction. This time you are going to do another 25% of the week’s average dose. You are still going to give it morning and night with the larger dose in the morning if the pills can’t be broken evenly.
At three weeks, another PCV, all normal? Only reduce the weekly amount by about 10%. You are going to attempt to give the dose every other day. If you see any signs of collapse, weakness etc. go back to daily dose every day. You are teaching the adrenal glands to work again, which is like teaching a child how to ride a bike with training wheels. Now you are no longer holding the bike for the kid.
Then another PCV. By now you should know whether she is handling this or not. If she is, then do another 25 % reduction, and give every other day. Or, do a 10% reduction and go to every three days. Always do the math to make sure that this is averaged over the whole week.
Continue at a very low dose, like 2 mg, every 3 days for a few more weeks. Then 1mg every 3 days. Then .5 mg.
If at any point there are other signs that are bothersome, the allergies get worse for instance, ask your vet to prescribe Temaril-P which is a combination of low dose prednisone and trimeprazine. This is well known to treat the itching of allergies very well. So you will be giving a lot less prednisone but also helping reduce the allergies.
Spilling a little protein in the urine needs to be followed carefully. This can be an indication that the kidney’s cannot handle protein well. The kidney diet reference I linked to will be helpful in reducing this occurrence. The kinds of proteins and the amount each day are the critical part of the diet. Mary would agree that most kidney dogs are not in crisis and they should continue to get proteins in their diet. The real thing to monitor is the phosphorous in the diet.
http://www.dogaware.com/health/kidneydiet.html
Mary says this: “If your dog has significant amounts of protein in the urine (urine protein:creatinine ratio above 1.0), then you may need to reduce protein moderately, enough to control the proteinuria, but a really low-protein diet is not considered beneficial, as it can lead to hypoalbuminemia (low albumin levels). It’s best to feed at least 1 gram of protein per pound of body weight daily (the grams of protein must be calculated from a nutritional analysis, it is NOT the same as grams of meat).”
The lab noted on Sophie’s urinalysis to “consider evaluation of the Urine Protein:Creatinine ratio. That is what Mary is referring to. We want to know this value. Once we know that we can feed Sophie properly.
http://www.dogaware.com/health/kidneysamplediet.html
There is also a great group that has been around a long time that has a forum of their own and they can help you with diet.
https://groups.io/g/K9KidneyDiet
Again, I dislike making negative comments about vets to owners and only do so reluctantly when I feel the dog may be at risk. Reducing prednisone very rapidly is like a ride on a very fast roller coaster. You can’t feel sick in the middle of the ride and just get off at that point, you are pretty much stuck until the ride stops. You might be able to finish the ride ok and not feel too bad at the end, but on the other hand you may feel pretty sick.
Are there other vets in your area? I could recommend you see another vet for a second opinion. Some vets hate this, they feel very competitive and resentful if an owner gets another opinion. But the reality is that clinics and vets all have different protocols for how they do things. Prednisone is just one of those protocols. It is a standard drug used for many things in both human and veterinary treatments. The reductions are pretty standard for most things and that is how your vet is approaching this.
On the other hand we have worked with owners for 12 or more years now. I see their tests, we read the details the owner shares with us and we have seen a combination of rapid decreases of prednisone and relapse a number of times. I have always felt that bruising the ego of the vet is less harmful than seeing a dog suddenly decline.
Any other questions? Did I answer everything you needed to know?
my best, Patrice
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
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
Hi Tracy,
I’m sorry to read about this difficulty with the treatment. It reminds me to explain that this condition, IMHA, is variable for a number of reasons, one of which is that it tends to be more predominant in certain breeds. There are always other triggers that combine to set off IMHA and in Cocker Spaniels one of these triggers is this genetic breed tendency.
Stabilizing at a PCV or HCT of 20% is quite common in the many dogs we have seen here. There can be a few reasons for this but the most common is called Anemia of Chronic Disease. And indeed, kidney disease is one such chronic condition that will most definitely lead to anemia.
Why? The kidneys have this complex relationship with the bone marrow, where all blood cells types are made. The kidneys are part of a very complex feedback loop that monitors the body and the need for oxygen going to the body cells.
So anemia, by definition, is not enough oxygen getting to the body cells. They “complain” and send a message to the kidneys “hey we need more 02 right now!” The kidneys then produce a hormone erythropoietin (EPO) that is responsible for stimulating the bone marrow. This causes the marrow to begin the blood making process called erythropoiesis. When the kidneys are not working well, this doesn’t happen, the message is not sent and the bone marrow “naps.”
So your vet should have explained this to you, considering there is a complication with kidney disease.
So at his age, with this condition, we can’t expect him to recover 100%. But we also can respect the quality of life that he is capable of having with good care. Monitoring the kidneys like your vet is doing, is a good way to evaluate his quality of life.
Older humans can begin to have kidney function loss and they can receive treatments for anemia if they chose not to get frequent transfusions. So, there are some treatments that humans get for the anemia due to poor kidney function. More recently two drugs with Erythropoiesis-Stimulating Agents (ESAs) have been approved by the FDA for use in humans. But an older ESA is a manufactured erythropoietin that is injected that has also been effective. This is called Epogen. Neither of these drugs are approved by the FDA for use in dogs, but never-the-less if a vet can obtain Epogen then it can provide a suitable treatment.
I was once in the position where the vet thought this might help Chance, since we could not figure out why he was not making blood. My vet had a connection with a local prison where she was able to obtain Epogen that was kept in supply at the prison for patients. Once it expired, they would donate that supply to her. So this is one avenue to explore.
As for the cyclosporine, he’s clearly having some trouble with it and this is not abnormal, the only significant side effect found in trials was this gastrointestinal problem but it tended to be short lived. I am cautious to advise that this drug may not be what is needed right now, but nevertheless, the prednisone needs to be decreased slowly now as the side effects are showing up such as poor body condition, shifting body fats, tremors, dehydration, weakness. The continued vomiting is causing dehydration and reducing the electrolytic blood balance. We need to change this to keep him stable!
In this case, since he is tossing the dose, it would be best to halve the dose at morning and night. Give the dose with a small portion of the morning meal and with a good snack at bedtime. This is going to significantly lower the effective dose, but if he keeps it down, as studies in dogs have shown, then after about a week or so he should be able to tolerate a slow increase and weaning the food supplementation. Dogs tolerate cyclosporine (Atopica) well and the side effects are much less than prednisone. That is why it has been so successful as a maintenance dose for dogs with severe allergies. If there are side effects, unlike prednisone, when the drug is stopped those side effects go away immediately.
So quality of life includes keeping him hydrated and eating a nutritious diet that works well with his kidney disease. I am going to send you to a friend’s website, Mary Straus has been keeping this complete site on nutritious alive and updated for many years. If you want to understand anything about diet, diseases and dogs, she has that for you. In particular please read her information on dogs and kidney disease. Once you have read that, click on her Diet for Dogs With Kidney Disease and follow one of several sample diets. I assure you that these kinds of diets work wonders for kidney dogs and contribute greatly to quality of life. You have the capacity to do this very well.
http://www.dogaware.com/health/kidney.html
If you have any more questions or just want to feel more love, please keep writing!
my best, Patrice
Chris,
I’m wondering if you could explain a bit more of the details of your dog’s diagnosis. What signs led you to seek treatment? What was the diagnosis in more detail.
What can you provide me in details from the current CBC and CHEM screen?
Treatments for IMHA have more recently become standardized and smarter in the last 5 years. Vet clinics are beginning to use protocols that address using a cocktail of immunosuppressive drugs and supportive supplements that provides a quicker reduction of hemolysis. Also they stabilize the patient by using drugs that reduce the risks of inappropriate and dangerous clotting such as low dose aspirin or heparin etc. This last part is always concerning as the risks of a dog becoming unstable during rapid hemolysis can lead to a clotting emergency.
So I’m not sure exactly what the stem cell treatment entails. Now if this was actually non regenerative anemia due to bone marrow failure, there might be some researchers who have experimented with some sort of stem cell transfusion.
However, most cases of canine bone marrow failure show up as non regenerative anemia due to an autoimmune attack to the precursor cells deep in bone marrow, which does often respond to these sophisticated clinical protocols. These precursor cells might also be thought of as similar to stem cells. Either is a type of blank cell that is prepared to become one specific type of cell.
So I am thinking that perhaps this is what you are trying to describe to me?
The most important element for out of control destruction of red blood cells is that this is an attack “on self” or the inability of the immune system to recognize “self.”
There can be, and usually are, multiple triggers, usually 2-5, that form together as a tipping point that leads to an attack on self. Those need to be identified as thoroughly as possible in case they are treatable. So think back and try to remember signs like this. Were there allergies, digestive upset that never resolves, exposure to bites or stings, recent vaccinations, drugs administered, viral disease or bacterial disease such as tick bite diseases or leptospirosis, doggie flu, urinary tract infections, an older dog might have an internal tumor, a younger dog may have eaten something dangerous.
If you have always trusted your vet, simply ask them why they are using the treatments they are. If you are uneasy you can always get a second opinion from another vet, that’s acceptable.
Give me a bit more information so i can help you.
My best Patrice
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