Immune Mediated Disease (IMHA)

[Denise Beeson]

The vet said keeping her on high doses of preds for a number of weeks is not a problem but she would not want her on them for 6 months!!!  She wants to transfer her to cyclosporin as she is adamant that she must be spayed before her next season and this cannot happen whilst she is on preds.

[Catherine]

Can you take Merry to see a specialist? I not sure your vet is very experienced with IMHA. I can not understand her wanting to keep Merry on high doses but not be on Preds longer than 6 months. The idea is to have the correct dose and reduce gradually - not to keep at a high dose longer than necessary for the PCV to start increasing and then try to reduce all within 6 months!

Why is there a hurry to spay Merry? Surely the idea is to get Merry better first and stable. Of course there are ideal times to spay to reduce the risks but unless there is a good reason the spaying should be something that only happens when Merry is recovered.

[Denise Beeson]

The vet thinks that if she comes in season the whole process will start up again and we will be back to square 1.  She must be assuming that this could have started as a result of hormonal changes as she was in season at the time.  This may be the case or it could have been purely random, no one really knows. Will let you know the latest bloods, which should be back Tuesday.
Thanks for your input.

[Denise Beeson]

Just received Merry's latest blood results.  PCV is up a little to 30, reticulocytes at 56.  IDEXX laboratories interpreted these results as positive as Merry is stable and red blood cells are not being destroyed and therefore needing a high reticulocyte production to replace.  The vet, therefore, is happy for her to stay on the preds only and not add additional immunosuppressants.  Next month she will look to reduce the preds again by about 20%. 
Really pleased with this as I was not comfortable with adding Atopica but was not looking forward to going against vet's recommendations.
Hope this goes in line with your thinking also. Please let me know if you have anything to add.  Your input is very welcome.

[Catherine]

As you say it is not certain that her season triggered the IMHA and surely the most important thing is to make sure Merry gets better first before any spaying?

Hopefully things are now going in the right direction but I would not wait a month to check. In fact I would suggest another blood test next week and if still okay you could start reducing the Preds a bit.

[Jo CIMDA]

Hi

This is good and I am pleased you are going to stay with the preds at this time.  I think it is worth trying the usual reducing protocol and see if the PCV increases.  I have known this scenario so many times before. Take a good look at the Michael J Day protocol and use this as a guide, checking all the time for drug induced clinical signs and respond accordingly.  I hope as you lower the preds the PCV will increase further. 

I totally agree with Catherine.  There is plenty of time to spay Merry and a season might not have triggered this anyway.  The potential triggers for AI disease are numerous.  It is a dilemma for anyone with an entire bitch, that has had a serious AI disease, whether to spay or not.  I have known some people who don't spay their bitch and a relapse hasn't occurred; and I have also known people who have spayed their girl but have waited until a long time after remission has been achieved and they are stable.  Putting a dog through a general anaesthetic and the stress and trauma of an operation has to be weighed up with the benefits of removing one trigger from their lives.  If, eventually, you do decide to spay then it is certainly worth finding a vet who is able to do keyhole surgery because the risks are so much less.

I would have another blood test in a week or two and not wait one month because if you can you need to reduce the preds further.

Jo

[Denise Beeson]

I will get another blood test done next week and if she is still the same level ask whether we can reduce the preds in line with your given protocol.  Her method of 20% per month is not far removed from your protocol chart but is very rigid, not taking into account how Merry is actually responding.  Merry has been on her current level since the 11 January so as she has shown no ill effects I feel a reduction is in order.  I also agree about the spaying as Merry will be in season again in June and I can't see her being totally free of preds by then anyway.  Also it is normal practice to spay a bitch mid season otherwise the blood supply to the womb is increased. 
It is unfortunate that I go on holiday on 1st February for 10 days, although I have a friend house-sitting worry that she may not notice changes in Merry's behavour as I would.

When you lower the preds, how soon afterwards would it be apparent that things were going wrong?

[Catherine]

Unless her PCV dropped dramatically I am afraid you would probably not notice much difference in Merry that is why the regular blood tests are needed to make sure things are going well.

[Jo CIMDA]

HI

I like your plan.  Always, the protocol has to be tailored to the individual and there is no way a dog on high doses of steroids ought to be left for weeks without checking on clinical signs - the adverse effects of the steroids can be as serious as the disease it is treating if a close eye isn't kept on the dog. 

When I asked  Prof Day's permission to use his protocol he agreed but strongly stated that it is a guide only and it has to be tailored to the individual.  Every day when you all wake up look at Merry and see that she is OK.  If she isn't then you have to respond to the signs you are seeing.  Generally, a part from infection because the immune system is being suppressed, as long as the primary disease is under control and heading for remission, the main clinical signs seen at this stage are usually down to the prolonged doses of steroids and this can be easily remedied by adjusting the dose. Difficulty in getting to her feet when lying down or going off her food and depression are the things to look out for. At the moment Merry is coping well and this is great and you want to keep it like this. If her next blood test is good then your vet should consider lowering the dose again.  It is a fine balance between the side effects of the drugs and control of the disease - and it isn't a case of one size fits all. The Prof Day protocol is the best guide I have come across.

It is highly unlikely that Merry will come into season in June because the steroids will inhibit her normal oestrus cycle.  When Merry is off preds, or even on a very low, every other day dose,  then her body will start to recover fully and start to get back into the normal rhythms such as oestrus, hair growth cycles, and all the other cyclic functions of her body.

You will have no idea when Merry will come into season again until you see the usual blood or discharge.  Then you can make plans, if you want to, to spay during the anoestrus phase.   

http://vetsci.co.uk/2009/12/28/the-oestrous-cycle/

http://www.villagedogs.be/time-spay-bitch/

Jo

[Denise Beeson]

Thanks again, will keep you updated.

[Denise Beeson]

Merry's blood PCV stable at 28, it seems to be staying between 28 and 30 now for a month.   The vet says to wait till I return from holiday and if she is still stable, will reduce preds in line with your protocol.  She still wants to move her on to Atopica in a couple of months so that the preds can be reduced much more quickly.  Merry is very well in herself with no clinical signs of any desease.  Back from holiday on the 10th so hopefully can progress then.

[Jo CIMDA]

Hi

Whoever is looking after Merry, tell them to keep an eye on her Cushing's symptoms.  If necessary the preds will have to be lowered.

I hope you have a good holiday. 

Jo

[Denise Beeson]

Merry has developed fat pads on the back of her neck.  Should I be worried.

[Jo CIMDA]

HI

These are fatty deposits as a result of the preds.  Nothing to worry about but it does indicate that she has had significant amounts of glucocorticoids. 

Jo

[Jo CIMDA]

This is quite an informative 'human'  article about the effects of prednisolone.  You can see the typical sites of fatty deposits.  It is the same in dogs.


https://www.hopkinsvasculitis.org/vasculitis-treatments/prednisone/

Jo