Relapse of IMHA....what does it look like?

[Carolshak]

Hi-  I'm new to this blog.  Our 10 yr. old Cocker was diagnosed with IMHA on 20 May, 2018.  His rbc was 8% upon admission.  After given an immediate blood transfusion, his count went up to 18 within hours.  He was in ICU for 4 days, each day gaining a few % points.  On day 5 he was released at 24% and put on the usual regimen of prednisone, cyclosporine, mycophenolate, and plavix for the blood clot risk.  He did very well over the last 3 months...they called him a "rock star."  They are weaning him off all meds - currently off everything except the prednisone....and we are down to 5 mg every other day for the last two weeks.  Every checkup was good, showing great gains.  On July 2 his count was 47%.  However, this week it went down to 37%.  So, is this the sign of a relapse?  Dr. told us that it could be from "other unknown factors, but is still within normal range."  She was going to reduce the prednisone even more, but just told us to continue with the every other day regimen.  For the first time in months we are concerned.  He is doing well otherwise....eating well, playing again, gums are bright red, no jaundice.  Anyone know if this kind of decrease is something that we should worry about.  Dr. wants to see him again in October.  Has anyone seen this kind of change?  Should we worry?  What are the odds of relapse with this kind of success?
Thanks.  - Carol

[Jo CIMDA]

Hi Carol and welcome

Your boy has responded well to treatment.  Does he have regenerative haemolytic anaemia (caused by destruction of red blood cells within the circulation of the blood or spleen, liver, or other secondary causes) or non-regenerative haemolytic anaemia (caused by an immune destruction of the immature red cells or precursor cells within the bone marrow)?  Has he had a gastroprotectant whilst he has been on the drugs?

This drop in PVC could indicate a relapse, and this is not unusual, so is this current drop due to the bone marrow not producing or blood loss elsewhere?
Also, ask if there is any clumping in the sample because this will give a false low reading.

If a dog hasn't had a gastroprotectant, such as Omeprazole or Ranitidine,  to protect the stomach from the excess acid that some drugs produce then even if the primary anaemia was non-regenerative sometimes a gastric ulcer can develop and this will cause regenerative anaemia. These are questions you should ask the Dr.   

Personally, I wouldn't leave the next blood test until October because you don't know if this trend will continue. Perhaps have another blood test done at your regular vets in a week or so.

Jo

[Catherine]

Sorry to be so blunt but I think he could be relapsing and having 5mg of Preds every other day will not stop the decline in PCV. What dosage did they start him on? Here is a recommended 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!

I feel it is much better to go slower in the reduction to lessen the chances of relapse. I agree with Jo not to wait until October. In fact, if he was mine, having experienced AIHA with a dog, I would err on the side of caution and take him for another blood test within a few days. Having done so well, it would be a shame for your dog to become very ill again. Hopefully the results will just show a blip or something minor but if he is relapsing then you will have caught it much earlier.

There probably would not be any obvious physical signs until the PCV was a lot lower, so really the only way to be sure is to check with blood tests.

[Carolshak]

Thanks to those who responded to my questions     I will indeed take Bogie to our regular vet (who likes to boast that he never lost a dog to the disease) next Monday for another blood test.  He was not treated by our regular vet b/c when this all happened it was a weekend and we went to the Emergency Vets.  They referred us to a specialist, in another city, in this disease.  She really saved his life..and very quickly....so we really have two very fine vets helping us.    And yes, his meds regimen was very much like the one that you recommend (Dr. Day's).  Bogie is approx 17kg so he started on 30 mg, given 15 AM and 15 PM.  The only real difference seems to be that she started weaning a tad sooner than Day's rec.  He was doing so well, maybe she started to wean too early.  We'll find out on Monday - and I'll keep in touch.  Again, thanks much.

[Carolshak]

Hi everyone.  I took your advice and got Bogie another blood test last week.  His count went down only one % point.   Now, as a summary, his count was 47 on 2 July....then it went down to 37 at 13 August.....and this last test on 28 August was 36.    I'm having him tested again on 15 Sept.   The last vet (his regular vet) said that it was still in the normal range...but suggested that Sept test.    Everything else is fine...his gums are red/pink, his appetite great, he's playing again, .....and still on prednisone, 5 mg every other day.
Again, thanks for your advice

[Jo CIMDA]

HI

You seem much happier about things now.  It is a good idea to have another blood test in a couple of weeks.  Meanwhile as long as you are seeing these positive signs then all should be OK and  I hope you will see an increase in PCV on the 15th.

Thanks for the update.

Jo

[Carolshak]

So, Bogie had a blood test on 15 Sept and it went up slightly from 36 to 38.  He is still on 5mg Prednisone every other day (he's approx 17 kg).  The regular vet asked that we finally stop all pred at the end of this month and re-test on 15 October.

I guess my question is this:  is NORMAL range in the high 30's?   Before reducing the pred he reached as high as 47%.  That made everyone happy.  But when the pred was reduced to every other day, he went down to mid 30's.  Vet keeps telling me that is "still in normal range." 

[Jo CIMDA]

Hi

Different laboratories have slightly different references ranges but it is generally considered that a PCV of  between 35-55 is within normal limits. Ask your vet for his labs' reference range.   

Certain breeds have a naturally higher/lower PCV than some other breeds for example greyhounds are very high and this is why the reference range is broad. A PCV of 35% for a greyhound is likely to be considered anaemic but this would not necessarily be so in another breed. 

I share your concern, but anywhere around the 40% mark I think would be considered normal.  It is not until several blood tests are performed when a dog is healthy that you can say what is the norm for that particular dog and even then the number can vary by a couple of degrees or so.

The pred may have influenced a PCV of 47% so this may not be Bogie's 'natural' level.  Also, was there clumping in the recent blood sample because if there was then this true PCV will be higher than 38? 

As long as there is no evidence of cells on the blood smear that indicate an ongoing immune destruction of the red blood cells it is likely the vet will want to continue to reduce the preds.  There is no reason why you can't reduce the every other day dose further (eg, 2.5mg EOD)  before stopping it altogether. 

I hope you will see a slight increase in the PCV when you have further reduced the preds.

Jo
 

[Carolshak]

Good news!

Thanks Jo, I did as you suggested and reduced the pred to 2.5 mg every other day for a week.....after that, cold turkey!    Bogie has been off all meds now for two weeks.  Just had another blood test today and he's UP one more % point to 39

The vet suggested one last blood test in another month, but overall he is very pleased.  It's been a long journey sine mid-May.  I believe that the initial and immediate blood transfusion that first day put him on track.  It's been slow, but upwards ever since -0 with the exception of a slight relapse scare  two months ago.  That prednisone is amazing.  Thanks for all your help and kind words.  You too are amazing
- Carol

[Jo CIMDA]

Oh Wow Carol.  Thank you so much for the update.  This is very good news and I hope Bogie's PCV will find its natural level and remain stable.  It is good to have another blood test in a month.

It's a long road to remission, with highs and lows, and it is a steep learning curve - although Bogie will not be aware of any of this!

Fingers crossed.

Jo