CIMDA

Introductions and other forum info => Tell us a bit about yourself and your dog/s and learn more about the forum. => Topic started by: Jabazb on March 01, 2020, 05:40:30 PM

Title: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on March 01, 2020, 05:40:30 PM
Apologies in advance for the long post. Our vet has been great and liaising with specialist throughout.

Archie has had IMT since January 2019. He has had a couple of relapses, a test for lung worm and other infectious diseases, x-ray, etc to check nothing else is going on i.e. that its not secondary IMT.

Archie has been off steroids since 20th Jan 2020 after a gradual tapering (as recommended by the specialist) over a period of 6.5 months. His final dose was one steroid (5 mg) every other day. Throughout the tapering, he had regular testing for bloods/ platelet count etc and all good.

We asked for another blood test once he’d been off of meds for a month for reassurance. Unfortunately his platelet count has dipped again after several retests this week ( 24th Feb-148,  26th Feb-100 & 27th Feb-down  to 78 😩) Archie showed no other signs of being ill?

Our vet spoke with the specialist Friday. They advised they cannot get imaging/scans/tests done today at the specialist hospital as he is not in a life-threatening emergency situation (thankfully) 🤞Therefore Archie is now back on 6 steroids and 1 omeprazole from today and has an appointment with specialist on Tuesday where he may or may not have to stay in.

Historically Archie responds well when on steroids but obviously this is not ideal.

Has anyone else experienced anything like this?
Title: Re: Help Please! Thank you in advance 🐾
Post by: Catherine on March 01, 2020, 06:22:37 PM
How much does Archie weigh?
Title: Re: Help Please! Thank you in advance 🐾
Post by: Jabazb on March 01, 2020, 07:06:06 PM
Hi he weighs 15.4 Kg
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jo CIMDA on March 02, 2020, 11:29:34 AM
Hi and welcome

I am sorry Archie has relapsed with IMTP.  Even after good and successful treatment,  this is not uncommon, but that doesn't mean that long term remission can't be reached - it can and does for most.   

Not showing other clinical signs of an IMTP relapse is usual.  It is only when the platelets fall below 40/50 that bruising starts to occur and even then there aren't usually  any other clinical signs, so it is good that you monitor Archie. 

Archie is on the right dose of steroids for his weight, so that is good news.  If the platelets are slow to regenerate there is a drug called Vincristine (given as a single shot) that has the ability of rapidly increasing the platelets, but this is usually only used if there is no sign of regeneration.   

It might be prudent, as Archie has relapsed, to add another drug to his regimen.  A combination therapy is often used when the dog has been on prednsiolone before.  Adding a second immunosuppressant drug allows the prednisolone to be reduced sooner, thereby limiting the side effects,  and still maintain a good level of immunosuppression.  Below is a good link to other immunosuppressive drugs.

https://www.dvm360.com/view/immunosuppressive-drugs-beyond-glucocorticoids

Archie responded well  last time and there is no reason why he shouldn't respond well this time.  There is no way of telling if a dog is in full remission. It is only by weaning down the drugs and then waiting and monitoring to see if the platelets stay within normal levels that you know if remission has been achieved.   Clearly, despite the gradual weaning down of the drugs, Archie wasn't in remission and as soon as the effect of the steroids had worn off the immune response against the platelets became active again.  The treatment protocol  and slow weaning down process that Archie received was good but you have to do the same all over again.  Maybe this time add another drug and also take the last stages even slower.  The protocol has to be tailored to the individual.

If a dog is in remission for a period of time, and then relapses, then the dog has met a 'trigger' to cause this immune reaction.  A dog who has had an AI disease should be kept, as much as possible, clear of all potential triggers and these include vaccination, flea treatments and unnecessary regular worming etc., and as stress free as possible.  The latter is difficult to control when day to day life can be stressful.  Also hormones are a huge trigger factor.  It is impossible to guard against all the potential triggers but the least you can do is to avoid things like vaccinations and chemical treatments that aren't necessary but are considered by some vets, a part of responsible dog ownership.

I do hope you see a good response to the treatment and then you can start on the reducing drug protocol and achieve remission.

Jo


Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on March 02, 2020, 04:27:34 PM
Thank you so much Jo, this is reassuring and really helpful.  I will read the link you’ve added.

Our vet indicated through speaking with one specialist that this was unusual because he said with his last taper (4 weeks of taking 1 tablet (5mg pred) every other day, he would have thought if Archie was going to relapse he would have done so then? We asked for the bloods to be taken after he’d been off steroids for a month and it was only through this, his low platelet count was picked up. Do some dogs have a fluctuating platelet count?

We are seeing the specialist tomorrow and I am expecting that they will keep Archie in hospital (which we are dreading) whilst they undertake further tests just to ensure this is not secondary IMT due to another condition (although he has had x-rays / imaging / other tests previously), this is a specialist hospital so they are much better equipped. 

We do still give Archie flea and worm treatment (Nexgard monthly for flea/tick & Milnemax every 3 months for worm)? We are worried what might happen if we don’t? However, we are not going to have vaccinations but will ask for a titre test. Archie is only 3 1/2 bless him and has been through so much☹️

Thank you once again, Jane and Archie 🐾 🐶
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jo CIMDA on March 03, 2020, 03:23:24 PM
Hi Jane

I hope Archie gets on well today.  Some dogs platelets can fluctuate but if it goes on for a long time then it is likely to be secondary or to be caused by destruction of platelets with the spleen etc.   I have know dogs with this problem and eventually the spleen has been removed and the problem is solved, but this would only be necessary if the low platelets were due to destruction other than a primary IMTP.

The best protocol I have come across is by Prof Michael J Day, and it can be confidently used as a guide.

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
This example is base 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.

The last reductions can be taken much more slowly, even reducing by one or two mg at a time, and then going from every other day to every third day and so on........  There is no wrong way when the dose is this low.

Personally, I wouldn't give any chemicals like flea/worming treatments etc., unless of course you see fleas or worms.  Most dogs these days don't grub around when they are outside the house and it is therefore  unlikely that they would get worms, and if they do you would see them in the faeces when you pick up.  One can always have a stool test done to see if worms are present.    The spot-on treatments can cause an adverse reaction.  It is safer not to give anything that is a potential trigger and deal with pests as and when it happens.  If Archie has been vaccinated as an adult dog then it is most likely he will have immunity to those core diseases.    You have to feel comfortable about your decisions, so don't take my word for it. ook up the WSAVA Vaccination guidelines.  It is sound advice and based on facts.  At a seminar I once attended, I asked Prof Brian Catchpole (RVC)   should a dog who has had an AI disease ever be vaccinated again, and his immediate reply was, "No".

It is likely because Archie is very young that he has a primary IMTP and he should respond very well to good a treatment regimen.

Fingers crossed
Jo

Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on March 04, 2020, 07:45:51 PM
Hi Jo,

It’s good news, well good news in the sense there is nothing else nasty going on, so as you suggested Archie has primary ITP, having carried out extensive tests (bloods, x-rays, body imaging, lungs, liver etc)

The specialist vet was brilliant and went through everything with us and said we can email her/contact her any time. She has been one of the specialists our vet has been liaising with which is good for continuity. The plan is as before, through discussion with our vet and specialist, gradual tapering of meds (steroids) every 3-4 weeks, but leaving him a little longer when we hopefully get to a lower dose (still testing regularly). This is I think as you are saying too.  His platelets were back up to 280 today after 5 days of steroids 😬

We are sticking with steroids at the moment, but specialist spoke about other options if needed. Archie seems to be able to cope with steroids at the moment 🤞

Thank you so much for your help, as I said it isn’t great that Archie has this condition, but 🤞this can be managed.

Jane and Archie 🐶🐾
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jo CIMDA on March 07, 2020, 06:22:48 PM
The rapid increase in platelets is brilliant news Jane and it indicates that Archie's bone marrow is able to regenerate once the destructive immune cells were suppressed. 

Like you say, take this round of treatment slower, if side effects allow, and if necessary add another immunosuppressive drug to support the steroid treatment, which will enable the pred to be reduced quicker.  Taking the last stages slower is often the best way to go and when the dose is low, and the side effects of the preds is minimal, then there is no rush to wean off altogether. 

This is an excellent start to the treatment.

Jo
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on March 09, 2020, 12:08:10 PM
Thank you Jo.  I will keep you updated with Archie’s progress 🤞

Many thanks again for your help and advice.

With very best wishes Jane and Archie 🐶🐾
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on May 17, 2021, 10:14:00 AM
Hi Jo,
I haven’t posted in a while (see previous posts over a year ago) but wondered if you could please give us some advice.

We are under a specialist vet for Archie, he has been on some dose of prednisolone since January 2019 with a couple of relapses and a very short period (4-8 weeks) with no prednisolone. Since March 2020, Archie’ dose has been very gradually tapered and we got down to 5 mg every other day in January 2021, however his platelet count dipped, so prednisolone increased again gradually (with monthly retests) to now 7.5 mg per day. His platelet count remains low (110) but specialist does not want to increase anymore, as other than platelet count Archie presents as a healthy dog. We obviously have to keep a close eye on him and contact the specialist if we have any concerns. The specialist said a platelet count of 50 or less is the area they would be most concerned about the risk of a spontaneous bleed. We are of course worried about the long term effect of steroids and whether they may stop working. Archie is only 5 in August.

Many thanks in advance, Jane and Archie 🐾

Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Catherine on May 17, 2021, 05:05:51 PM
I would have thought if Archie's platelets had started to go down again to a certain degree and at each blood test that he was relapsing. In that case he would have needed an immunosuppressive dose of steroids straight away not a gradual increasing.

What is the normal range for platelets? It may be that Archie will always be at the lower end of normal but without all the test results it is hard to make a judgement.

Hopefully Jo will be along soon to advise you.
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jo CIMDA on May 17, 2021, 06:19:06 PM
Hi Jane

I am sorry that you have the need to post again, although it is always good to hear from people.

There are two major/common causes of thrombocytopenia. Has the specialist ascertained whether the low platelets count is because the bone marrow isn't producing enough or if there is a destruction of platelets within the spleen/liver etc.    As this seems to be a reoccurring problem for Archie, I do think that this needs to be established because it could determine the right, necessary treatment. 

If the destruction is within the spleen then often the removal of the spleen rectifies the problem.  Supportive treatment such as blood transfusion may be necessary during and just after the operation if the platelets are very low.  Alternatively it would be prudent to get the platelets to a good level before surgery, if that is possible.   With this sort of IMTP the platelets can remain low and not get to the stage of bleeding and bruising because the bone marrow is still able to replace the destroyed platelets, even at a lower level than normal.

If it is a primary autoimmune cause and the bone marrow isn't producing any immature platelets then it is immunosuppressive treatment but as Archie has been on steroids for a considerable length of time, it would be prudent to consider a 'combination' immunosuppressive drug such as mycophenolate mofetil.  So9 I would put this question to the specialist and depending on his answer, perhaps a new plan of action can be made.

What breed of dog is Archie.  Some breeds such as greyhounds and whippets can have  naturally low platelets and this is not a problem to them.

I do hope you manage to have a good chat with the vet to see how you can move forward and keep Archie stable.

Jo
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on May 17, 2021, 09:13:30 PM
Thank you Jo,
This has given us a lot to think about and to discuss with Archies specialist. Just to let you know Archie is a cockapoo.
We take Archie directly to the specialist for his blood tests as opposed to via our local vets to avoid any issues with the sample in transit. Our vet describes Archies platelets as being ‘sticky’ with lots of clumping. They usually have to do a manual count as well as a machine count to get a more accurate reading.
Many thanks once again, Jane & Archie 🐾
Title: Re: New Member. Help Please! Thank you in advance
Post by: abriel on May 18, 2021, 01:39:51 PM
Thank you for helping me with this. 1baiser
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jo CIMDA on May 19, 2021, 09:19:08 AM
Hi

Clumping can be caused when the blood is taken.  The red blood cells and platelets can get damaged through the vacutainer blood collection tube.  Taking blood with a larger tube and from the jugular may avoid damage to the cells. If there is clumping then the actual count is always much higher.

All the best
Jo
Title: Re: New Member. Help Please! Thank you in advance 🐾
Post by: Jabazb on May 21, 2021, 08:42:29 AM
Thank you Jo, your help is much appreciated.
Kind regards, Jane