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Author Topic: Ginni  (Read 218 times)

cassapple

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Ginni
« on: July 07, 2018, 04:36:06 PM »

Hi thank you for the add. Ginni is a 2 1/2 year old English Springer Spaniel who was diagnosed with IMHA on 16th March. Since then she has been on prednisalone and azathioprine. Her pcv is hovering around 33 and we can’t get it any higher. The vet has now added cyclosporine. She is also on phenoleptil as she started fitting in December. The fits coincided with her season and the IMHA started when she was diagnosed with a pyo. Am looking for any advice available as I’m at my wits end
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Catherine

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Re: Ginni
« Reply #1 on: July 07, 2018, 06:37:07 PM »

What dosage of prednisolone and azathioprine is Ginni on now and what dosage was she started on? It is essential that the correct dosage is given at the beginning and that the dosage is slowly reduced when the PCV increases. What was her PCV in March? Sometimes if a dog is on an immunosuppressive dose of steroids for longer than necessary the steroids can inhibit production of red blood cells within the bone marrow and if this happens it is not unusual for the PCV to plateau around 30%. In many cases, when the steroids are lowered (gradually) the red blood cells starts to increase.

Here is a medication protocol that is recommended:

Oral Prednisolone in the Dog.
Ref: Clinical Immunology of the Dog & Cat by Michael J Day  – Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.

This example is based on a dog receiving an induction dose of 1.0mg/kg/q12hrs (every 12 hours).

Dose                Duration (based on clinical effect)

1.0mg/kg/q12h             10-28 days
0.75mg/kg/q12h            10-28 days
0.5mg/kg/q12h             10-28 days
0.25mg/kg/q12h                         10-28 days
0.25mg/kg/q24h                         10-28 days
0.25-0.5mg/kg/ Every other day      at least 21 days
0.25-0.5 mg/kg/ Every third day       at least 21 days

Azathioprine (a cytotoxic drug) can be used in combination with prednisolone at 2mg/kg/24 or 48 hrs and dose gradually reduced, when remission is achieved, over a period of months.
Clinical response to Azathioprine may take up to 6 weeks. (Plumb’s Veterinary Drug Handbook)

Don't forget the gastroprotectant!

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[][/Also there is some information here: http://cimda.co.uk/smf/index.php/topic,11.0.html and here: http://cimda.co.uk/smf/index.php/topic,16.0.html
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cassapple

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Re: Ginni
« Reply #2 on: July 08, 2018, 08:25:54 AM »

Ginni's PCV was 17 on 16th March she started on 25mg prednisalone twice a day and 25mg azathioprine once a day which was increased to 50mg once a day about a week later. we started weanimg the preds and she's now on 25mg am and 10mg pm and this week they added atopica as well as her PCV is slightly dropping and is now 32.5. my worry is she's being over supressed
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Catherine

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Re: Ginni
« Reply #3 on: July 08, 2018, 12:23:36 PM »

If Ginni weighed about 25kg then that was the correct dose to start with. That was almost 4 months ago so going by the protocol I gave in my previous post I would say, if her PCV has been steadily increasing that she should by now be   on a dose of Preds at 12.50mg a day and ideally soon reducing to 6.25mg a day plus the Azathioprine.  Certainly the current dose of 35mg of Preds a day seems too high and could be delaying the rise in PCV.

Is Ginni on a gastroprotectant?
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cassapple

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Re: Ginni
« Reply #4 on: July 08, 2018, 01:38:05 PM »

Ginni weighed 22kg at the start which has dropped to 20.3. I guess that’s muscle wastage as her appetite is good in fact she never lost it. I must admit I’m a bit concerned she’s over medicated especially now atopica has been added. She’s due another blood work up tomorrow. The latest smear show she wasn’t really generating red blood cells so there is talk of a bone marrow biopsy which I’m not keen on
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Catherine

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Re: Ginni
« Reply #5 on: July 08, 2018, 02:49:25 PM »

Yes the steroids will do that, but when the steroids are reduced and hopefully finished she should regain most if not all of her muscle especially as she is a young dog.

Personally I would not be keen on the Atopica especially as the other medications do seem to have been doing their job with the increase in PCV from 17% to in the 30%s.

My dog became very ill with AIHA and got better with just the Preds. and the Azathioprine. We reduced the medication very gradually but not too slow to affect the red blood cell production.

If she is not regenerating red blood cells it could be as I said earlier, it could be the steroids now causing it. I would not be keen either on a bone marrow biopsy and my dog with AIHA did not have one done. Here is an excerpt taken from a post that Jo Tucker (CIMDA), the Administrator has posted on the forum: " Blood testing and examination of a blood smear is vitally important to a diagnosis of AIHA.  Your vet, however, may want to perform a bone marrow biopsy, but this is an intrusive procedure, especially in a very poorly dog, and is now considered a ‘diagnostic overkill’.  A diagnosis of non-regenerative AIHA is often achieved by elimination of other primary or secondary causes of anaemia and, on examination of a blood smear, the absence of immature red blood cells. " and "Prof Day is among the few top immunologists in the world.  He is Chairman of the WSAVA vaccination guidelines committee, and has many other accolades, and is based at Bristol Vet School. It is the best protocol I have come across and the one that yields most success.  There are no guarantees but using a tried and tested protocol that is tailored to the individual gives the best chance."

[/color][/b]You may want to take some of the information and medication protocol to your vet and see if you can both come to an arrangement that you are both happy with when considering Ginni's next treatment. If your vet is not experienced with AIHA it might be an idea to see a specialist who is.

If you go with reducing the steroids I would have her blood tested in a few days time again to see that things are going in the right direction. Good luck!
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cassapple

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Re: Ginni
« Reply #6 on: July 09, 2018, 10:10:46 PM »

Pcv today was 34 so slight increase so we are reducing preds from tomorrow with another blood test on Monday unless she dips then I will rush her down there earlier. There was a slight improvement in her liver values as well. Ideally I would like to reduce the azathioprine but my vet isn’t happy to that. So far she’s tolerating the atopic quite well.
« Last Edit: July 09, 2018, 10:19:33 PM by cassapple »
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Catherine

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Re: Ginni
« Reply #7 on: July 10, 2018, 11:26:51 AM »

Sounds good, what are you taking the Preds down to? My AIHA dog was on 25mg of Azathioprine to start with but the vets, nowadays do seem to want to give the higher 50mg dose, not sure why.

I found it best to  reduce only one medication at a time and the Azathioprine was the last to be reduced - I reduced the Preds until it was just the Aza and then that was reduced gradually. It is quite frightening seeing the elevated liver values but in most cases they do go back down again to normal when the steroids are reduced.
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cassapple

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Re: Ginni
« Reply #8 on: July 11, 2018, 05:40:43 AM »

Preds down to 15mg am and 10mg pm. My vet says if all goes ok next bt next Monday we’ll start to drop the azathioprine as well
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Jo CIMDA

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Re: Ginni
« Reply #9 on: July 15, 2018, 10:42:59 PM »

HI

Sorry, because of being on holiday I have come to this discussion late.  Catherine has given some really good information and I agree that the preds should have been weaned down sooner and this might be why the PCV is staying around the early 30's. Anecdotally, when a dog has been on high doses of steroids for many months the PCV often plateaus around 30-34% and it is not until the dose of preds is reduced that the PCV will start to rise. This might be due to the saturation effect of preds and suppression of bone marrow production.

The Michael J Day protocol is the best I have come across and it can be confidently used as a guide.  Prof Day is among the world's top vet immunologists. 

It is often assumed that the plateaued PCV is still due to the AI disease but this is very unlikely as the amount of preds being given will be significantly suppressing the aberrant immune system, especially with the addition of Aza, so it can reasonably be assumed that the low PCV isn't the AI disease but it might be either suppression of bone marrow production or if it is a regenerative anaemia and the dog hasn't received a gastroprotectant such as Omeprazole or Ranitidine,  then it could be caused by a bleeding gastric ulcer.  This is not an uncommon scenario.   

Azathioprine can also suppress bone marrow production but if Ginni is coping with the Aza then, as Catherine suggests,  perhaps it might be prudent to only reduce one drug at a time.  Generally if a dog is coping with Azathioprine and it has been on preds for many months, it is more important to lower the preds to a low daily dose and then start to reduce the Aza. 

You might like to give Ginni Denamarin to help with her high liver values.  Denamarin is a combination of Milk thistle and SAMe.  You can give these individually if you prefer.

I hope (and expect)  the PCV will rise as you lower the preds.

Jo
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litex

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Re: Ginni
« Reply #10 on: August 05, 2018, 10:20:58 AM »

sometimes just a little time, patience and a good specialist and everything will work out perfectly. I'm glad that everything is good!