IMHA after vaccinations and now stuck at 26-30%

[julieo21]

Hi all...I was directed to this forum today after some questions on a Facebook group for IMHA Dog Owners. History: Bella, 5 1/2 year old Jack Russell/Chihuahua mix, never sick once in the entire time I've had her. I thought since she's always been healthy I would just take her to a Petco (Vetco) for vaccinations last August. I believe it was the cause of her IMHA. Within two weeks she had an emergency blood transfusion from a donor dog. Her HCT was 7.7%. That was 13-Sep-2017. Treated with prednisone and then weaned off by December and was looking like she was going to get to healthy levels. On 26-Dec-2017 I was going to have a dental appointment but had to check blood work first. She was at 26%. By January 8, another emergency transfusion and she was at 6.9%. We started with prednisone and azithrioprine but she was back down to 10% two weeks after transfusion. Switched to Cyclosporine 100 mg two times a day and prednisone 10 mg two times a day (she's 20 pounds). She had a packed red cells transfusion and has been slowly going up but her highest since September has been 30.5%. She was 30, then 27 the next week, back to 30 then yesterday was 26%. We're still at 10 mg prednisone twice a day and at 50 mg cyclosporine twice a day. Are there other things we should do? Decrease prednisone? Switch or add azithrioprine? My vet is consulting with a specialist tomorrow and going to call me to see what to do but I'm so worried. She dropped so fast in January but she continued to eat and drink ok. At 6.9% she still wags her tail. The vets are really just amazed by her will to live and what a tough little girl she is. Any advice is appreciated!

[Jo CIMDA]

Hi and welcome

I am sorry Bella has IMHA.  I don't doubt that the trigger for Bella's IMHA was the vaccination.  I presume, initially, she had non-regenerative IMHA? On a positive note you know that her red cells can regenerate and she has in the past responded to the treatment.  The aim now is to get her to stay in remission and perhaps the way to achieve this is to take the last reductions very slowly and perhaps leave her on a very low every other day dose of prednisolone  - for many months at least.

As Bella is only 20lbs body weight she weighs 9kg. After 2 months Bella is still on an immunosuppressive dose of prednisolone and this should be reduced.  Little dogs can be really tough and the good news is they tolerate the steroids much better than larger dogs but she shouldn't be on an immunosuppressive dose for any longer than one month, unless there is very good reason, and if there is very good reason then it is likely that another drug will be introduced so that the preds can be significantly reduced.   

A starting immunosuppressive dose of prednisolone should be 1mg/kg/12hours, and this is weaned off in a similar fashion to the excellent protocol by Prof Michael J Day.    See below:

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.

Anecdotal evidence suggests that when a dog has been on immunosuppressive doses of prednisolone for a long time the red blood cells can plateau round the 30% and it isn't until the dose of prednisolone is lowered that the red blood cells will start to rise again.  A small dog on 20mg of pred a day and Cyclosporin will certainly be immunosuppressed so at this time there is no risk of a relapse - a relapse may or may not occur when the drugs are much lower and not given at an immunosuppressive dose.  So the usual way forward is to gradually lower the preds (still maintaining her with the Cyclosporin) and over the next few days/weeks it is hoped that the red blood cells will gradually start to increase.  I have known this scenario many times before and everyone is so surprised when you start to lower the preds and the PCV starts to increase. 

I see no point now in dosing with excessively high doses of prednisolone when her PCV is around 30% and she is still on the Cyclosporin.
Personally I don't think she need the addition of another immunosuppressive drug, and not Azathioprine because that is known to cause bone marrow suppression.

I hope you have a good meeting with your vet today and he or she can see the benefit of starting to reduce the preds especially as you still have the back-up of the Cyclosporin.

Jo