CIMDA

Yes, it could have been that Amy.  If it is regenerative I hope you will see a rise in her PCV very soon.  It can be low one day and back to normal the next when it is regenerative anaemia.

Good luck
Jo

Hi Jo
She has regenerative anaemia - I’m back later so will discuss further with the vet about an underlying cause.
I treated her with a flea tablet earlier that week so I’m wondering if it was that. Poor ezzy.

Thanks for your help
Amy

Hi

I am so sorry that you recently lost your dad, and now you have another problem with Ezzy.  It can be all too much sometimes, but with a close eye on Ezzy and the correct treatment, she can bounce back again.

 Your vet seem to be very vigilant, so that is good.  Do you know if the anaemia is regenerative or non-regenerative? Below is some information about anaemia.


(AIHA) Non-regenerative Autoimmune Haemolytic Anaemia 
A dog can be anaemic from either blood loss (internal bleeding), or destruction of the red blood cells, or a decrease in their production in the bone marrow. 
There are many reasons why anaemia might develop, eg.  Immune mediated destruction of the red blood cells occurring within the circulation of the blood is known as regenerative immune mediated haemolytic anaemia.  This can be secondary to: tick borne diseases such as Lyme disease, cancer, haemangiosarcoma, parasites, poisoning (zinc, onions etc.), a reaction to drug administration, hyperthermia, systemic disease etc.
or
Primary non-regenerative AIHA (an autoimmune destruction of the immature red blood cells, or the precursor cells, within the bone marrow) where there is no detectible underlying disease.

Primary non-regenerative immune mediated haemolytic anaemia (NRIMHA) may also be termed as acquired Pure Red Cell Aplasia (PRCA).  It is thought that NRIMHA progresses to acquired PRCA and therefore the term PRCA is interchangeable.
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If her red blood cells are regenerating within the bone marrow then Ezzy may be anaemic due to a gastric ulcer, or destruction of the red blood cells within the spleen etc.   With regenerative anaemia there may be an underlying cause, so this has to be investigated. Your vet will be able to tell from a blood smear if there are immature red blood cells present.

If Ezzy has a primary non-regenerative anaemia, ie., no underlying cause and the immature red cells, or precursor cells,  are being destroyed within the bone marrow, then immunosuppressant drugs such as prednisolone (and many others too) may be used.  As Ezzy has had three bouts of immune mediated disease it might be prudent for your vet to use a second drug alongside prednsiolone, such as Azathioprine, Cyclosporine etc., to give added immunosuppression and also to enable you to reduce the dose of prednisolone perhaps sooner than usual to avoid extreme side effects.

It also might be prudent, as Ezzy has relapsed, to keep her on a low maintenance dose of an immunosuppressive drug for much longer than before, to give some protection against it occurring again so soon after the last episode. Some dogs are maintained on a low dose of drug for life, and some are on a low dose for a year or so before the drug is gradually withdrawn over a period of time. 

This is a good article discussing different immunosuppressant drugs that can be used to treat AI diseases.

http://veterinarycalendar.dvm360.com/immunosuppressive-drugs-beyond-glucocorticoids-proceedings

For a dog to be in remission and then have a relapse, or develop a different AI disease, the dog has met a trigger that has caused the immune system to malfunction and target, in Ezzy's case, the red blood cells, or the immature red blood cells.  So where possible, limit 'trigger' factors such as flea treatment, vaccinations, stress etc.   If you can cast your mind back and try to remember if Ezzy has encountered a potential trigger in the last weeks, you may be able to identify the trigger and avoid it in future.

The correct treatment regimen is crucial to the outcome and this protocol by Prof Day is the best I have come across 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
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.

Prednisolone:  "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.


If Ezzy is on the correct drug and protocol then if she has non-regenerative anaemia the you should see a rise in red blood cells within 5-7 days.

I do hope you see an improvement very soon.

My condolences for the loss of your Dad.

Jo

Hi so our springer Ezzy was first diagnosed with IMTP back in Feb 2018. She improved well and was steroid free for around 6 month before her first relapse. Again her platelets dropped - we managed to pick it up early and she perked up quickly. She’s been off steroids again for 2 months and now is anaemic. She’s been back on her steroids since Friday. RBC was 24 last Friday and is 19 today. I was allowed to take her home but having daily blood tests til she either improves or she needs a transfusion. I’m so sad- I lost my dad recently and this is all just so hard. Any advice gladly welcome.

Hi Jane

Sorry for the late reply.  I have been away from the computer for a few days.  I think your tapering plan  for Shiva is perfect.  There will be very little effect on this dose and even less on the planned reduced dose but it is always better to take things steady and slowly if possible.  How is the calcinosis.  I hope it is improving now he is on such a low dose of pred.

I have read with interest the article link you gave and it brought to mind the genetic difference in individuals (even in siblings) can have a huge bearing on whether they have the genetic predisposition to AI disease or not, and also whether they have the necessary genetic make-up to block potentially harmful drug toxins.  Why are some of us allergic - or do not  have the genetic make-up to tolerate some of these modern drugs?

In some breeds of dog there is a described genetic mutation called MDR1 gene mutation.  If the dog is positive for this mutation  (meaning that the gene is not complete) it can have a dreadful reaction to many, commonly used, modern drugs.  In humans, I am aware of a similar genetic mutation called, dihydropyrimidine dehydrogenase  (DPD) and if an individual has this mutation then it can be catastrophic if given a certain chemotherapy drug.  Unless this dpd genetic mutation is tested for,  just one dose of the drug can cause serious brain problems and even death.  So I believe there is so much more to learn about the genes of the individual (whether it be dog, human or other) and the body's response to certain modern drugs. This is a relatively new area in medicine and genetics.

I had a bearded collie with demodex mange because his immune system was compromised by the steroid treatment given for an AI disease.  I was aware of the MDR1 gene mutation, especially in collies, so I was reluctant to use Ivermectin but after trying everything else I reluctantly used a  1/4 of the pipette.   He was fine.  Three days later on the Vet's advice I used another 1/4  of the pipette and within one hour his neurological symptoms started and they were alarming.  Luckily I was aware of this potential so I stopped the drug and within 3-5 days he was back to normal.

Returning to Shiva, I would believe your eyes and not read too much into blood results at this time, and certainly not until the effects of all the steroids Shiva has had has well and truly left his body.  There are  so many incidental things, such as food -  and the even stress of going to the vets,  that can alter blood results and if you took blood the following day they could be entirely different.    If the CRP is within normal limits then I think that is something to be relieved about.

You have done really well managing Shiva's AI disease and he has done so well to have responded to the treatment and is almost at the end, and ready to enjoy being drug free. Hooray!

Jo

No, I only use when there is a problem, I would not use it all the time. I will give the diarrhoea a chance to get better on its own but if not and the dog seems fairly okay otherwise I will give some paste for a few days. I keep some in stock although the best before date is not always that long. I do forget what side the "measure" has to be so I have made a note of that for future use!

To administer the correct amount of the product use the handy wheel on the syringe plunger.  Rotate the wheel until it is to the right of the number representing the desired quantity to be administered.

I have not tried the Pro-Kolin + as I found the Canikur Pro worked without any side effects so decided to stick with that.

Catherine, I meant to say: we didn't get to the Canikur Pro paste but used slippery elm and now psyllium as well as Protexin probiotics. Stopped the probiotics for a week at the height of the diarrhea but have reintroduced to help rebuild gut biome. Do you use the Canikur pro paste regularly in a healthy dog or just when there's a problem? It does look like good stuff from the ingredients. Thank you so much for having been there for us. What do you think of this product, compared to Canikur? Have you used it? Is Canikur Pro preferable? : https://www.protexinvet.com/pro-kolin/p6230

Just an update, Jo.

We're on week 4 of 6 weeks at 5mg every third day for 31kg Shiva, an extra tapering step I've added on to the Lowrie protocol for the sake of the adrenals, given we've been on pred now for 10 months. Will do 2.5mg every third day next and then off completely.

Repeating blood tests next week which will be a month since the previous ones. The monocytosis is certainly explained by the pred so I'm not worried about that reading, but the elevated band neutrophils and the slightly elevated WBCs, and the C-reactive protein that's gone up but still within normal, are actually NOT explained by the pred, according to the link you shared, so really want to see those values normalise and not be part of a slide back towards any SRMA. All those values have been normal in some of our earlier blood test results, when pred dose was much higher. At the moment my best theory is that it's something to do with either the diarrhea he had (now resolved with first slippery elm and now psyllium husk which avoids the oxalates in slippery elm that are a kidney/bladder stone risk) or the pred-caused calcinosis, though I haven't seen any reference in any literature to calcinosis showing up in bloodwork, except for sometimes in elevated Calcium, which we don't have. We do however have elevated phosphates, which are the other component of the plaques formed in calcinosis.

I also thought you might be interested in this article. It was you who first warned me of Tri/Sulpha and you're the (godsent!) reason we managed to avoid using that antibiotic when the vet (who knows we're recovering from SRMA!) suggested it. The other antibiotic I'm aware of as being associated with causing meningitis in dogs is Metronidazole/Flagyl. But this article from human medicine also mentions others like Amoxicillin and NSAIDs. https://www.mdmag.com/journals/resident-and-staff/2005/2005-12/2005-12_02

Hope things are good your end.

Thanks again for everything.

Thanks very much Jo, that's promising! Hopefully we can have success too.   

Hi

That made me laugh.  while Finn still has the energy to cuddle your leg then he must be feeling good.

One of my boys had systemic SLE and he was on steroids for life.  His testicles shrunk as a result of the immunosuppressive treatment, but he was still a happy boy.

The CRP test is an important marker of inflammation, but isn't reliable if a dog is on prednsiolone therapy as it can reduce the CPR marker, and therefore give false low results.  It is a marker for many chronic inflammatory diseases and therefore not specific to a particular disease.

Finn has done remarkably well.

Jo