PRCA

[VickyM]

Hello,

Thank you for adding me to the group. I am looking for as much advic and information as possible, my cockapoo has just been diagnosed with PRCA, we are devastated as she is only 6 months old. We nearly lost her as her pcv dropped to 7% but thankfully after an emergency transfusion she pulled through. She is now on prednisone and omeprazole. I am struggling to find information regarding her condition, we've been told it's quite uncommon especially in a dog of her age. I know very little of what her future holds, I don't know if it's a curable condition? will she be on meds for life? will it shorten her lifespan? what affect will the steroids have on her long term?  .. so many questions and no answers 

Would be great to get some advice from anyone who has beeen through this or knows more about it as all I can find online are a couple of medical studies, and is there anything we can do to help her along the way.

Thank you x

[Jo CIMDA]

Hi and Welcome

I am sorry your little cockapoo has PRCA.  It is very alarming when this happens, it seems to come out of the blue and it is a lot to take in.  The good news is she seems to be doing well.

PRCA is the same as non regenerative autoimmune haemolytic anaemia (AHIA) and it is sometimes termed as non regenerative immune mediated haemolytic anaemia).  There are many people here who have had a dog with AIHA (AIHA for the sake of simplicity because it is the most common term).

Autoimmune disease occurs when a dog with a genetic predisposition encounters a 'trigger' that causes their immune system to malfunction and is then programmed to destroy its own cells. In your girl's case the immune response was targeted against the precursor cells in the bone marrow and as the natural dying off of the red blood cells within the circulation of the blood progressed the bone marrow was unable to replace with immature red blood cells from the bone marrow and over a period of weeks her red blood cells depleted until such time that she became so anaemic her body could no longer function properly. 

As autoimmune disease only affects dogs with a genetic predisposition, it is not curable but with the correct medication long term remission is  achievable. I have known numerous dogs to have achieved long term remission and have had a good long life without drugs. So she won't necessarily have to be on drugs for life.  It is not ideal for a young dog to have steroids, but they have saved her life. Your vet might consider introducing a drug called Azathioprine to help with the steroid treatment.  Azathioprine will take 6+ weeks to kick in but after that time it will give added immunosuppression and this enables the vet to lower the steroids a little quicker and still maintain a good level of immunosuppression.

The best way forward is to limit the trigger factors as much as you can and that means to keep her a natural as possible eg., no more vaccinations, spot-on treatments and regular preventative treatments such as flea and worming etc. Try to feed her a natural diet too.   If you would like my seminar notes, please email me at cimda@aslog.co.uk and I will email them to you.  There is too much information to post here.

AI disease is most common in young to middle age dogs, so although it might not be common for a 6 month pup to have PRCA it is not unheard of either.  The youngest pup I have known to have AIHA is 3 months of age.

  The most important thing now is to make sure she is on a good immunosuppressive drug protocol. See below the best I have come across by Prof. Michael J Day, one of the world's leading veterinary immunologists.

Extract from Seminar Notes:

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.

How Do I Know if My Dog Will Relapse?
Until you have attempted to wean your dog off of the tablets for the first time you will not know if he is likely to relapse or not.  Sometimes during the weaning off process, before you even get down to an every other day dose, he may relapse.  If this happens then the drug dosage has to be raised, probably up to the last dose before the relapse (maybe a little higher, depending on the severity of the relapse) and then start the weaning process again.  If this happens again, then you and your vet may have to settle for keeping him on a low maintenance dose to achieve a good quality of life. A low, every other day maintenance dose of prednisolone is preferred to enable the dog's liver to rest in between doses. There are many autoimmune diseases that carry a good, drug free prognosis.  The more common, serious autoimmune diseases that may not need long term steroid therapy are: primary immune-mediated polyarthritis, autoimmune haemolytic anaemia and thrombocytopenia. However, as previously stated, all dogs are different and it very much depends on the individual dog, the severity of the disease, the experience of the vet and the vigilance and compliance of its owner.
If a relapse occurs whilst the dog is still being treated then true remission has not been achieved.  If the dog has achieved remission and has enjoyed a period without drugs or is on EOD maintenance drugs, when a relapse occurs or he develops another autoimmune disease, he has encountered a 'trigger factor' which has induced this change.

As long as she is on a good drug protocol I hope you will start to see an increase in her red blood cells.  Sometimes puppies need a bit more time and sometimes a higher dose of prednisolone before the bone marrow kicks back in, but the good news is you have a diagnosis and she has pulled through the initial stages.  It is good she is on a gastroprotectant.

Jo

[VickyM]

Thank you Jo for all the information it has certainly helped answer a lot of my questions. Can I ask why not to worm or flea her? Would that not put her more at risk from ticks, fleas and worms? I have read that high dose steroids can make dogs extra hungry, do you have any advice as to how to combat this without making her over weight?

I will definitely be asking my vet about Azathioprine if it can help her than I am willing to try anything xx

[Jo CIMDA]

Hi

Regular PREVENTATIVE worming and flea treatments are harsh chemicals and a potential trigger factor for a dog with a genetic predisposition to autoimmune disease, as is vaccinations.  If a dog has worms (and you will see worms in her stools when you pick them up for disposal) then of course you have to treat for worms, but preventative worming every few months is absolutely not necessary, especially if your dog doesn't grub around and eat anything they can get hold of when you are out walking. So if they haven't got it, then don't treat it. 

There are lots of natural flea and tick preventatives on the market that can be used to make your dog unattractive to these pests and don't want to latch on, so best to use these as a deterrent.  I always use a combination of lavender oil, eucalyptus oil and rose geranium oil  (15 drops in total) mixed with 500ml water and a little hair conditioner and use this as a grooming spray.  If she does get fleas then you may have to use a chemical such as frontline but I wouldn't use the spot-on type, just use the Frontline spray on the coat only (not the skin) and this can be used in an open space and allow her to run around to dry the coat. You may have to treat your home with Indorex but make sure she is out of your home for a few hours to allow the fumes to subside.

You must try to use a few chemicals as necessary in order to limit the trigger factors that may cause a relapse or another AI disease. I attended a seminar by Prof Brian Catchpole,  at the Royal Vet College, a while a ago .  I asked the question:  Should a dog with an autoimmune disease ever be vaccinated - or spot-on treated again? and he immediately said "No".  He said the benefits  always have to outweigh the risks and when a dog has a genetic predisposition to autoimmunity the risks are too great.

Steroids will make her want to eat and drink more - and this is a good sign as it means that the drugs are having effect.  Unfortunately you may have some wet pants or have to take her out in the night to have a wee but this is only temporary and it will reduce as the drug dose is lowered.   Don't restrict her drinking. Try to make sure her diet is low in fat to avoid the risk of pancreatitis.  Chicken, turkey and low fat cottage cheese are all good forms of protein. Pred redistributes fat, so even if you restrict her diet she may get fatty deposits on parts of her body.  I wouldn't worry too much about any weight gain because when she is feeling much better and she is on a lower dose of preds you can take her for lots of exercise to get her figure back.

Let the steroids do their job and get her back to good health and then you can see what you have to address.

I hope she is doing well.
Jo

Some info about:


WHAT TO EXPECT ONCE 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 anytime 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.
Side Effects of the Drugs – Iatrogenic Cushing's Syndrome
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. 
All drugs carry side effects and Azathioprine is no exception, but it does not carry the same side effects as prednisolone, therefore by using this drug in combination with prednisolone it reduces the risk of iatrogenic Cushing's syndrome.  As Azathioprine takes at least 10 days to take effect, starting the 'combination' therapy at the beginning of treatment may enable the prednisolone to be lowered within the 10-28 day band and still maintain a good level of immunosuppression. If your dog is not responding to treatment then your vet may consider changing his treatment to other immunosuppressive drugs.
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.