CIMDA

Hi and welcome

I am so sorry Lucy has IMHA.  If she is in the vet hospital then they should know the best way of treating her.  The blood transfusion should buy Lucy time for the drugs to work.  IMHA can be regenerative (blood loss or destruction of the red blood cells within the circulation of the blood or by the spleen etc) or non regenerative (this is when the bone marrow is no longer able to produce the immature red blood cells within the bone marrow because they are being targeted by the immune system). 

If it is non-regenerative IMHA, it will take at least 5 days for new red blood cells to migrate into the circulation of the blood following immunosuppressive treatment.  The treatment regimen is crucial to the outcome and the best immunosuppressive regimen I have come across is by Prof. Michael J Day.  Prof Day is one of the worlds top immunologists.

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.

I do hope you see an improvement in Lucy very soon.

If you have any queries, please get back to us.

Jo
 

Extract from my seminar notes:
WHAT TO EXPECT ONCE IMMUNOSUPPRESSIVE TREATMENT HAS STARTED
If a dog has a serious autoimmune disease, then the sooner treatment commences the better chance the dog has of survival.  The main delay to starting treatment is obtaining a diagnosis or at least your vet being sure that he hasn’t missed anything that could be made worse by giving high doses of steroids.  Achieving a diagnosis can be a fight against time. 
If your vet has decided that in all probabilities your dog has an autoimmune disease, then to a certain extent, which autoimmune disease your dog has, as far as treatment is concerned, is irrelevant because with the exception of a few diseases, they are all treated the same, that is, with immunosuppressive drugs.  The main objective is to ‘knock out’ the immune system and virtually stop it from working (or near enough) so the destruction will cease and give the body a chance to recover.  As previously stated, this treatment regime works in most cases, that is, if it has been given early enough and the dosage is correct.  All dogs are different and some can tolerate the drugs better than others. In proportion to their size, small dogs seem more able to tolerate higher doses of steroids than large ones. Some diseases are more serious than others and carry a poorer prognosis. So the initial crisis is a crucial time, however anecdotal evidence shows that many more dogs survive than die if correct treatment is administered in good time.
It is hoped that a positive response can be seen within 4-6 hours of starting treatment (depending on the disease), but in a serious, life threatening situation, the first 2-7-14 days can be a very worrying time.  Assuming the dog has stabilised he will quickly feel much better, and if he is in hospital may be allowed home within a week.
When he comes home he will probably have a ‘goody bag’ full of drugs.  He will be on a high dose of steroid, usually prednisolone, and he may also be on another immunosuppressive drug, such as Azathioprine.  Your dog will be weaned off in a controlled manner according to his wellness and clinical observations. 
Note: High doses of steroids must not be stopped abruptly.  Your dog could go into an adrenal crisis if the medication is withdrawn too quickly. 
In addition to immunosuppressive drugs he should have something to protect his stomach from excess acid.  The last thing your dog needs when he is feeling poorly is a bleeding stomach ulcer caused by the drugs.  Sometimes, Antepsin is given to coat and protect the stomach (but this must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed).  Zantac (Ranitidine) may also be prescribed to take away the excess acid. Another gastroprotectant used is Omeprazole. To minimise irritation to the stomach it is usual for the daily dose of steroid to be split into two doses and given with food, one dose in the morning with breakfast and the other dose with his evening meal. I have known several dogs, who did not receive a gastroprotectant as a part of their treatment regime, and went on to develop anaemia. This is not autoimmune haemolytic anaemia but iron deficiency anaemia caused by bleeding stomach ulcers. Using a gastroprotectant is a good preventative measure. When the steroids have been significantly reduced to a low dose, a gastroprotectant may not be necessary.
Excess acid, produced because of the drugs, may make a dog prone to developing pancreatitis. A dog with pancreatitis will appear in pain and his back may be arched as if he can’t straighten up.  He may be lethargic, seem bloated and have a tender abdomen. Dogs usually go off food and water, may vomit and look depressed.  If you suspect that your dog has pancreatitis, don’t try to feed him because it will make the condition worse. Take him to the vet as soon as possible as he may require treatment or need to go on an intravenous drip to stop him dehydrating.  Again, the risk of pancreatitis should be minimal once the dog is on a lower dose of steroids.   A low fat diet is best when your dog is on high dose steroids or prone to pancreatitis. 
As your dog‘s immune system is being significantly suppressed, he will be more likely to pick up infections, and will not have the ability to fight against them.  As a precaution a broad spectrum antibiotic is often prescribed. Also it is sensible not to exercise him in areas where he is more likely to encounter infections, for example, a park or a popular dog walking area. 
Whilst your dog is on high dose steroids he will want to eat and drink excessively. However, this also means that he will want to urinate more and this can sometimes cause temporary incontinence.  You may have to get up to let him out during the night and if you leave the garden door open during the day, it may save some mopping up!  He cannot help it and won’t like it either, so don’t be too hard on him, it’s only temporary. You will notice as he is weaned off the drugs the unwanted side effects will subside and he should return to normal habits and behaviour.  Urinary tract infections and/or bacterial skin pustules are not uncommon when a dog’s immune system is suppressed, and this is often the reason for a dog to be off colour during this time.  Note: Always consider a urine infection if your dog seems under par.  A course of antibiotics will usually sort this out quickly.
Depending on what autoimmune disease your dog has, he will probably need to have regular blood tests.  Biochemical blood tests will also keep an eye on other body functions, such as those of the liver and kidneys, which is important at this stage.
Assuming good progress is being made, the clinical signs of his illness are diminishing and positive signs of improvement are apparent, your vet will want to start weaning him down from the high doses of steroid.  This process can take 3-6 months or more, and usually begins any time after 10 - 28 days from the start of treatment, depending on the results of his blood tests and his clinical signs.
Relapses are not uncommon, especially in diseases that are difficult to control, for example SLE.  A relapse may mean that initially, your dog needed to be on a higher dose of immunosuppressive drugs for a longer period of time, or your dog may have been weaned off a little too quickly and then the dose withdrawn too soon.
If a relapse occurs he will probably show similar clinical signs to his initial crisis.  He will have to go back on an immunosuppressive dose of prednisolone, but it may not have to be quite as high as before. A combination drug may need to be added at this stage. The weaning process will then have to start all over again. Returning to an immunosuppressive dose will mean that he has to go back on a gastroprotectant.

Brilliant news.  I am so pleased, and I can feel your relief!
Jo

Thanks for the reply Jo,
We reduced Mouses Preds to just 1 (5mg) tablet a day around a week ago. All signs are good, she’s had some good, longish walks since and is enjoying herself in the garden. She had a little run a couple of days ago. She’s interacting with us more and spending less time just laying around. Remembering that as a lurcher her normal state is upside down on the sofa! I think that after nearly six months of struggling with this horrible disease we are finally getting somewhere. Fingers crossed.

My dog Lucy (a Springer) was diagnosed with IMHA yesterday after falling ill on Sunday. She's at the vet hospital on medication and having a transfusion this afternoon.

Hello.  Thank you for the update on Mouse. 

It is difficult to know if the limping and stiffness is due to a relapse of the disease or due to the long term use of preds.   If a dog relapses then it is very likely they will have swelling around the joints and a high temperature.

Long term use of preds, especially in a lurcher dog, will take its toll and weight loss can be expected.  Other breeds are more inclined to put on weight but sighthounds are different because they have a faster metabolism. Also, muscle loss is inevitable and this will result in a stilted gait and tiring easily with fatigue.  These symptoms can be confused with a relapse of the disease.

This time around, as long as the adverse effects of the preds allow, try to take the reduction slower and nip down each reduction eg., 1mg at a time,  as opposed to reducing the dose by 25%, and get the dose as low as you can before going to every other day dosing.   You can take it as slow as you like as long as the Cushing's symptoms are not a serious problem.

I do hope the reduction works this time around, and Mouse is tearing about as she should be very soon.

Jo

I think it's like looking for a needle in haystack! Also have the issue that we can't use Piriton when he gets hives so I have no idea what we're going to use instead now if it happens as we can't use antihistamines with Phenobarbitol. 

Hello. I thought I should share my experience so far. Mouse was diagnosed with IMPA at the end of February, she has followed the recommended drug protocol on this site as prescribed by out referral vet. Her recovery has been text book to the point of reducing her pred to every other day. We noticed she was getting periods of stiffness and some pain in her joints again. This would happen every few days and last for about 2 days. Our vet recommended we step back to the daily dose of 7.5mg once a day for another 4 weeks. This seems to suit her and she was fine for more than two weeks then had another couple of days stiffness. She is eating and drinking normally, regaining some of her cheeky personality but still a bit slow on walks and hasn’t had a proper run since January. We are expecting to try the drop to every other day again next week. I’m really hoping we are not seeing relapse. Could the stiffness and slight lethargy be symptoms of steroid use rather than return of the IMPA? I’m really hoping so as she’s doing so well, from a very poorly indeed little lurcher in February to about 90% her old self now in July. Before becoming ill she was 17kg, she dropped as low as 12kg prediagnosis and is now 18.5kg. I’d like to get her back to full fitness, she’s just 5 years old and was a very fast girl who lived to run.

Hi an welcome

I am sorry your collie has AIHA.  As Catherine has posted, it is so important that he is on the correct dose of prednisolone, even if he is on other immunosuppressive drugs.

I do hope you see a rise in his red blood cell count very soon.

If you are unsure about anything, please get back to us.

Jo

What medication is your dog on? You need to have him on the correct dose as well - not too much and not too little. Here is a good medication protocol:

Immunosuppressive Protocols for 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!


Have you seen here: http://cimda.co.uk/smf/index.php?topic=11.0 and here: http://cimda.co.uk/smf/index.php?topic=16.0

If there is anything you need to know just ask.

Hello, I’ve been pointed in the direction of your forum by a friend. My collie was taken ill last Sunday & quickly diagnosed with AIHA. He had one blood transfusion & his levels have started to rise & remain stable. I am finally bringing him home today but am very nervous about doing the right thing.
Any help advice & guidance will be gratefully received!