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Author Topic: Second relapse but RBC dropped this time  (Read 39 times)

tildesaz

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Second relapse but RBC dropped this time
« on: September 02, 2019, 07:35:07 PM »

Hi so our springer Ezzy was first diagnosed with IMTP back in Feb 2018. She improved well and was steroid free for around 6 month before her first relapse. Again her platelets dropped - we managed to pick it up early and she perked up quickly. Shes been off steroids again for 2 months and now is anaemic. Shes been back on her steroids since Friday. RBC was 24 last Friday and is 19 today. I was allowed to take her home but having daily blood tests til she either improves or she needs a transfusion. Im so sad- I lost my dad recently and this is all just so hard. Any advice gladly welcome.
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Jo CIMDA

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Re: Second relapse but RBC dropped this time
« Reply #1 on: September 03, 2019, 11:14:02 AM »

Hi

I am so sorry that you recently lost your dad, and now you have another problem with Ezzy.  It can be all too much sometimes, but with a close eye on Ezzy and the correct treatment, she can bounce back again.

 Your vet seem to be very vigilant, so that is good.  Do you know if the anaemia is regenerative or non-regenerative? Below is some information about anaemia.


(AIHA) Non-regenerative Autoimmune Haemolytic Anaemia 
A dog can be anaemic from either blood loss (internal bleeding), or destruction of the red blood cells, or a decrease in their production in the bone marrow. 
There are many reasons why anaemia might develop, eg.  Immune mediated destruction of the red blood cells occurring within the circulation of the blood is known as regenerative immune mediated haemolytic anaemia.  This can be secondary to: tick borne diseases such as Lyme disease, cancer, haemangiosarcoma, parasites, poisoning (zinc, onions etc.), a reaction to drug administration, hyperthermia, systemic disease etc.
or
Primary non-regenerative AIHA (an autoimmune destruction of the immature red blood cells, or the precursor cells, within the bone marrow) where there is no detectible underlying disease.

Primary non-regenerative immune mediated haemolytic anaemia (NRIMHA) may also be termed as acquired Pure Red Cell Aplasia (PRCA).  It is thought that NRIMHA progresses to acquired PRCA and therefore the term PRCA is interchangeable.
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If her red blood cells are regenerating within the bone marrow then Ezzy may be anaemic due to a gastric ulcer, or destruction of the red blood cells within the spleen etc.   With regenerative anaemia there may be an underlying cause, so this has to be investigated. Your vet will be able to tell from a blood smear if there are immature red blood cells present.

If Ezzy has a primary non-regenerative anaemia, ie., no underlying cause and the immature red cells, or precursor cells,  are being destroyed within the bone marrow, then immunosuppressant drugs such as prednisolone (and many others too) may be used.  As Ezzy has had three bouts of immune mediated disease it might be prudent for your vet to use a second drug alongside prednsiolone, such as Azathioprine, Cyclosporine etc., to give added immunosuppression and also to enable you to reduce the dose of prednisolone perhaps sooner than usual to avoid extreme side effects.

It also might be prudent, as Ezzy has relapsed, to keep her on a low maintenance dose of an immunosuppressive drug for much longer than before, to give some protection against it occurring again so soon after the last episode. Some dogs are maintained on a low dose of drug for life, and some are on a low dose for a year or so before the drug is gradually withdrawn over a period of time. 

This is a good article discussing different immunosuppressant drugs that can be used to treat AI diseases.

http://veterinarycalendar.dvm360.com/immunosuppressive-drugs-beyond-glucocorticoids-proceedings

For a dog to be in remission and then have a relapse, or develop a different AI disease, the dog has met a trigger that has caused the immune system to malfunction and target, in Ezzy's case, the red blood cells, or the immature red blood cells.  So where possible, limit 'trigger' factors such as flea treatment, vaccinations, stress etc.   If you can cast your mind back and try to remember if Ezzy has encountered a potential trigger in the last weeks, you may be able to identify the trigger and avoid it in future.

The correct treatment regimen is crucial to the outcome and this protocol by Prof Day is the best I have come across and it can be confidently used as a guide.

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.


If Ezzy is on the correct drug and protocol then if she has non-regenerative anaemia the you should see a rise in red blood cells within 5-7 days.

I do hope you see an improvement very soon.

My condolences for the loss of your Dad.

Jo

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tildesaz

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Re: Second relapse but RBC dropped this time
« Reply #2 on: September 03, 2019, 02:22:42 PM »

Hi Jo
She has regenerative anaemia - Im back later so will discuss further with the vet about an underlying cause.
I treated her with a flea tablet earlier that week so Im wondering if it was that. Poor ezzy.

Thanks for your help
Amy
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Jo CIMDA

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Re: Second relapse but RBC dropped this time
« Reply #3 on: September 03, 2019, 05:08:39 PM »

Yes, it could have been that Amy.  If it is regenerative I hope you will see a rise in her PCV very soon.  It can be low one day and back to normal the next when it is regenerative anaemia.

Good luck
Jo
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