New Member- Help with Taper after 2 weeks with no PCV increase?

[LLBean]

Hello. Thank you for adding me, this came highly recommended by others with IMHA dogs.
My 9yo Boxer was diagnosed with IMHA on 10-13-17 with PCV of 19% and low platelets as well.
Stayed 3 days at the vet for IV steroids, bringing her PCV to 24%. She was released home to have oral meds.
(She had thyroid cancer in the spring of this year. Her weight dropped from 55 to 52) Her weight at the time of hospital release was 46lb, but she should be at around 52 pounds. I think that is 23 kg.
Started at 25mg of Prednisone every 12 hours & 50mg of Azathioprine daily. on 10-16-17
(also on milk thistle, slippery elm & tagamet appropriately given 4-6 hours from Prescriptions)
Her Pcv went down to 21% on 10-19, up to 22% on 10-21. And back to 21% on 10-27-17.
Took bloodwork for a Reticulocyte test to see if her bone marrow is regenerating, should hear results by 11-21.
At that last visit, the vet gave me a new prescription to begin tapering Pred.
Wants her to go to 10 mg every 12 hours. He said nothing about tapering Azathioprine.
I didn't question it at the time, but I realized at home that this taper seems fast and no mention of alternating Azathioprine.
Questions...
Since her PCV is just holding steady and not climbing, is it too soon to taper Prednisone?
And if not, is the 50% reduction too much without a great improvement?
Also on Azathioprine, should we be done with the loading dose after 14 days daily? Is she ready to taper to every other day of 50mg?

I will be talking to my vet in a few days and it was recommended by some other IMHA owners that I get credible info here to back me up when speaking with my vet on taper concerns. Thanks in advance!

[Catherine]

Do you know whether the platelets have increased as well? If your dog has both low red blood cells and platelets  together it could mean she has Evan's Syndrome see here: http://cimda.co.uk/smf/index.php/topic,13.0.html  Also see here for AIHA and treatment regimes: http://cimda.co.uk/smf/index.php/topic,11.0.html  and  http://cimda.co.uk/smf/index.php/topic,16.0.html

My dog had AIHA and we reduced very slowly and had blood  tests every few days in the beginning. What was your dog's last PCV and when was that? I would not reduce until the PCV started climbing and even then only a little and then test a few days later to keep a check on things.

It sounds like you need to reduce slower if your dog is coping reasonably well with the steroids. The Azathioprine will take some time to start working. My dog had Azathioprine as well as the Preds. and the Azathioprine was the last medication to be reduced then stopped. Only reduce one medication at a time and I would say the Preds and leave her on the Azathioprine until the Preds are quite low.

Here is the medication protocol from this site:

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 base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

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!

[LLBean]

Thank you! I'll read over all this today!!
Regarding Platelets, she was in a very low range initially at diagnosis. Her platelets doubled and went into the Normal range within 6 days on steroids. Although I've heard Steroids falsely bring up platelets. My vet didn't rule out Evans syndrome completely, but he said the treatment would be the same even if it was Evans.

[LLBean]

Oh, I missed your second question...
Her last PCV was 21% on 10-27-17. It was 22% on 10-20 & 21% on 10-18.

[Jo CIMDA]

Hi and welcome

I am sorry your Boxer has IMHA. It is likely she has Evan's syndrome because her platelets were low at the same time as the PCV.

Do you know if she has primary, non-regenerative AIHA or regenerative?  They can tell this by looking at the initial blood results to see if there are high reticulocytes present (regenerative) or none at all (non-regenerative).  If the bone marrow is regenerating then the number of reticulocytes should reflect the level of anaemia. 

The protocol that Catherine has copied for you is the best I have come across and Prof Day is one of the top immunologists in the world so his immunosuppressive drug protocol can be confidently used as a guide.  The recommended protocol should be adapted to the individual.

Unless your girl is reacting badly to the preds then she should be on an immunosuppressive dose of prednisolone for at least 2-3 weeks, and until the PCV has shown a significant rise (at least over 30%) or even within the reference range. 

Generally, if you can keep her on the initial immunosuppressive dose, side effects permitting, there is less chance of a relapse during treatment.   If she is coping well with the side effects of the drugs then you can eek the duration out - say to 14 days, 16 days, 18 days etc....... checking all the time on her clinical signs and watching out for those unacceptable side effects of the drugs.   If you can get to 21 days and the PCV is over 30% then you might want to lower the dose but lowering it by 25% and not 50% might mean that she has less chance of a relapse.  What you want to avoid is reducing the preds too soon, thereby releasing the destructive immune cells that are targeting the red blood cells, or the precursors in the bone marrow.

The treatment is the same for AIHA or Evan's syndrome, but Evans can be more difficult to bring under control and this is why you need to be doubly sure (as much as one can) that the steroids have done their job before reducing them.

Azathioprine doesn't start to have effect for at least 10 days and it may take 6+ weeks for it to have full effect so you don't want to start lowering the Aza until you know that the PCV is stable and within normal range.  As long as your girl is tolerating Aza then there is no need to rush the reduction. Very often the pred will be significantly reduced, perhaps to every other day dosing,  or even weaned off before the Aza needs to be reduced.

I hope the above has answered your questions, but if not please let us know.

Jo

[LLBean]

Thank you so very much, this is all helpful and affirming to some things I've wondered as well.
In regards to regenerating, blood was sent off Friday to determine that & I'm hoping to hear good news tomorrow on the Reticulocyte test.
Not for sure if its primary, but she had thyroid cancer diagnosis in January of this year with a delicate surgery to remove huge tumor and one of thyroid glands. No chemo/radiation, but I changed to homemade diet & supplements.
So we assume the Cancer was the trigger for IMHA.

[LLBean]

Update on my dog. She was diagnosed with Pancreatitis yesterday. All the signs, not eating with vomit & arched back plus bloodwork confirmed it.  So she is receiving IV meds & fluids at the vet until stable. Doctor is looking at switching her from Azathioprine to Cyclosporine. Hoping this one isn't a step down with side effects or effectiveness against IMHA.
Once she is stable, we will talk about her new meds protocol/dosage.
Good news is her PCV held at 22% through all the pancreatitis.
So my dosage questions seem irrelevant now

[Jo CIMDA]

Hi
I am so sorry your girl has pancreatitis.  I hope you are able to manage it.  It can be tricky but there are different stages of pancreatitis so I hope hers is mild and chronic as opposed to severe and acute.  I am sure the vet has suggested to give her a low fat diet. 

Azathioprine can cause pancreatitis and so can prednisolone so when the Cyclosporin kicks in you should be able to lower the prednisolone as well.

Pancreatitis is a known side effect of immunosuppressive treatment, not all dogs on immunosuppressive treatment get it, but it is no surprise when it happens.

I hope she improves very soon.

Jo