Hello

[Janice]

Hi,
My name is Janice I have 2 Spaniels Hugo & Dave we live in Hampshire in Titchfield Common a little area 5 mins from the beach ...sadly Dave has IMHA he was diagnosed early July we have been on a hidious roller coaster ride ever since.....Davey is 5 years old

[Jo CIMDA]

Hi Janice and welcome

I am sorry Dave has IMHA.  Can you tell us a little about how he is coping now and if he has any worrying clinical signs and what is his PCV or HCT now?  The drug protocol is crucial to the outcome and if that is wrong then remission is very difficult to achieve.

Hope to have more information from you soon.
Jo

[Janice]

Hi Dave was diagnosed early July he initially had a blood transfusion as his bloods went down to 9 he was on 75mg Atopica twice daily 35gm Prednisone half a tablet of Clopidogrel and Omeprazole 20gm twice a day... He is now on 15gm of Pred per day as his liver was being effected he is very very thin losing weight daily boney coat is dreadful and it has never really grown he is very anxious ie doesn't rest he has dreadfully smelly wind and very runny poo.... often sicks up  his dinner and will refuse his pills. Really don't know if he has a quality of life ....his red blood count is great up in the 40s has also been tested for Pancreatis but that was okay was given anti biotics and a paste cleared up but now back again

[Jo CIMDA]

Hi

Well the good news is Dave has a PCV of over 40. 

If he has always tolerated the Atopica then it is probably not that which is causing the clinical signs you are seeing.  It is more likely to be the prednisolone   I don't know how much Dave weighs but  considering it is 5 months after diagnosis he should be on much less pred by now.  I will copy Prof Day's reducing immunosuppressive drug protocol  for you to compare treatments.  The symptoms you describe are typical of a dog who has been on high doses of preds for a long time and if you lower the dose you will see a marked improvement within days.  He is still having the Atopica to play a role in the immunosuppressive treatment so it is time to reduce those preds. 

He is on a very high dose of omeprazole and I would question if he needs this dose.  Also it is recommended that a dog be on Omeprazole for a period of 8 weeks only*.  Omeprazole 0.5-1.5mg/kg/24hrs*   If a gastroprotectant is still necessary then you can change to Ranitidine  2mg/kg/8-12hours*   Ref: *BSAVA Small Animal Formulary.   (these can be bought from the chemist or even the supermarket).

Dave has done very well and so had your vet for doing a transfusion and starting treatment but there is no reason with a PCV over 40 why Dave should still be on 15mg of pred a day.  This should be weaned off now.  See the information and protocol below:

Jo

Side Effects of the Drugs – Iatrogenic Cushing's Syndrome[/b]
Iatrogenic Cushing's syndrome is a side effect of high dose steroids and is caused by too much corticosteroid in the body. To a lesser extent, the immediate side effects observed when the dog initially goes on steroids eg., drinking, eating and urinating excessively is a mild example of Cushing's syndrome.  Personally I like to see dogs responding to high doses of prednisolone in this way, as it means that they are responding to the drugs as they should.
Usually, Cushing's syndrome only becomes a real problem when exceptionally high doses, or prolonged high doses of steroids are administered, maybe due to a relapse, or in some cases where the vet is inexperienced in reducing steroid doses and keeps the dog on a high dose for longer than necessary; or when the dog is not responding to treatment and higher doses are necessary to control the disease.  This is where the cytotoxic drug Azathioprine is very useful. 

How Can I Tell if My Dog Develops Iatrogenic Cushing's Syndrome?
Iatrogenic means 'drug induced'.  Clinical signs of Iatrogenic Cushing's syndrome are the same as primary Cushing's syndrome but can present with acute clinical signs. It reflects the level of corticosteroid in the body.
The most notable side effects are, heavy panting, some hair loss, and an increase in drinking and urinating, excessive pigmentation.  This is something everyone seems to be aware of and accepts as normal when a dog is on high dose steroids. Very often the dog will be weaned down to a low dose before any major problems arise. 
Acute Cushing's syndrome due to overdosing of corticoid steroids can be very serious.  Blood results will reflect this, especially the liver enzymes which may be extremely high. Red blood cells and blood platelets may also be high and blood clotting may be a risk.
So when should you alert your vet to suspected, unacceptable level of corticosteroid?  The owner should take note when other clinical signs occur, such as: Depression, anorexia, muscle wasting and extreme weakness, continuous panting, lethargy - unwillingness to exercise, skin lesions and thinning of the skin, excessive hair loss, pot-bellied appearance and sagging back, behavioural changes (aggression).
If your dog is showing these signs it will probably mean that the dose of steroids needs to be lowered. It is important that it is not confused with a relapse of the dog's condition or an infection. The dilemma is that steroids must not be withdrawn too quickly otherwise the dog may go into an adrenal insufficiency crisis.  If the clinical signs of iatrogenic Cushing's syndrome is intolerable, it is hoped that the high dose of steroids that he has been on will have already done their job and that his autoimmune disease will be stable. As long as the steroids are lowered in a controlled manner and in time, all the symptoms of Cushing's will subside and your dog will return to normal, but extreme signs must not be ignored.

Reducing the Tablets
When significant improvement in the dog's condition is seen, usually between 10-28 days, the initial steroid dose is usually reduced by up to half. The dose is generally given for another 10 - 28 days and depending on the dog's progress and clinical signs the dose is significantly reduced once more for a further 10-28 days; and again in another 10-28 days. Anecdotal evidence has shown that if at this stage the dose is lowered more slowly, or reduced to an every other day dose over a period of months rather than weeks, relapse are less likely to occur.  It is always tempting to get your dog off steroids as soon as possible, but when treating autoimmune disease, as long as the dog is on a low, every other day dose then taking the last stage slowly seems to work best, depending, of course, on the severity of the disease and allowing for the difference in individual response - no two dogs reactions are exactly the same.  With some autoimmune diseases such as SLE, the dog is likely to be on steroids for the rest of his life. Usually an every other day dose can be achieved, but you risk a relapse if you take the dose too low. Below is the best example of a reducing immunosuppressive protocol I have come across. It is an excellent guide and can be adjusted to the individual.

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael DayBSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 
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/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.
"Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.