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Author Topic: Early stages of IMHA diagnosis  (Read 246 times)


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Early stages of IMHA diagnosis
« on: January 05, 2019, 09:46:00 PM »

Hi everyone,

I have been pointed towards this forum by one of my Facebook friends and I am so grateful to have found it because I feel like I am going through hell.

I have an 11 year old Large Munsterlander who quite suddenly on New Years Day went very wobbly (I describe as drunk!), seemed to be very unsteady on her legs. She collapsed to the floor and prior to this had urinated some blood/haemoglobin. I scooped all 35kg of her up and put her and my other Munster in the car and rushed her to the vets who automatically began testing for IMHA (I had never heard of it). Her PCV was 19 and she was admitted and given immunosuppresives (azathioprine and pred), plus omeperazole. Anyone that knows the breed will be aware how anxious and sensitive they can be away from their normal environment. The next day, the vets said we could bring her home as she was quite nervous in the kennels.

She was put on 30mg (2mgs/kg) pred, omeperazole and azathioprine. She ate, drank, passed urine and faeces normally, although was panting very heavily. On the second day, Isla vomited quite severely - large amount of blood and clots which was just horrific. The vets suspected something had upset the stomach lining -
 ethey took her off azathioprine, gave her a stomach liner of sucralfate and injected with zantac + antibiotic. Day three she was much better - but still low in demeanour and panting heavily. She was eating, drinking, urinating etc. PCV count after blood vomit was 18, but yesterday it was up one to 19 (I am holding on to every shred of positivity).

Today is day four and we awoke to the tiniest bit of vomit - not bloody as before but a light brown. Vets not too worried about it but she went off her food and wouldnt eat any of the Royal Canin tins. Munsters can be selective anyway, and she was very selective with what she ate and dubious about any meds in there. We got to a point where she wouldn't eat at all. Eventually we have managed to get food down her (boiled chicken) and I am elated that she is eating.

We are having the blood smear on Monday. I feel like I am on an emotional rollercoaster - I am crying and then elated. Can someone tell me that they have experienced the same? Is this "normal"? Would you expect to see reticulocytes on Monday,  5/6 days after the initial pred dose and consistent drug regime? Has anyone experienced this increased panting?

I'm sure many of you have been clutching at straws and I just would love to hear from people to know that we are not alone it what appears to be a lonely and desperate place. My girl is my life and I know in my heart that she has years ahead of her.
Thank you.



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Re: Early stages of IMHA diagnosis
« Reply #1 on: January 06, 2019, 10:01:28 AM »

Hi and welcome

This scenario is not unusual when a dog has AIHA but urinating and vomiting blood makes me wonder if she also has low platelets, if so the two AI disease together is called Evan's syndrome.

An immunosuppressive dose of prednisolone should be 1mg/kg/12hours, so if she weighs 35kg then from your account she is not on enough prednisolone.    I will copy the best immunosuppressive drug protocol I have come across and it can be confidently used as a guide.   It is by Prof Michael J Day a world leading immunologist.

If the dose of pred is correct then you could see an increase in the PCV within 5-7 days and the reticulocytes hopefully will be high.  Some dogs take longer than others to start to regenerate and you may have to give it more time before you see an increase in PCV.  If the PCV gets below 12% then a blood transfusion will buy time.  This is a common procedure.

I do hope you have better news on Monday.


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 25%. 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.

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.


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Re: Early stages of IMHA diagnosis
« Reply #2 on: January 06, 2019, 12:11:51 PM »

Your dog needs to be on at least 35mg of Preds TWICE a day (total 70mg daily) to start with so 30mg daily is not enough for a dog weighing 35kg and without the correct dose her PCV will continue to lower.

I had a dog with AIHA and it was a rollercoaster and it is tiring, physically and emotionally, looking after a very ill dog especially when you do not know too much about the disease. If your vet has not had much experience of AIHA then a specialist might be better. I do think you need to sort out the correct dosage as soon as possible.

My dog had AIHA many years ago so it was very difficult to get a diagnosis and the correct treatment but it was worth all the worry as she got better and went on to live a long and healthy life. I hope your dog can too.