holly

[christina]

Hi again n thanks for listening
X
Holly gets prednidale once a day imorning
Would it be better spaced out twice a day?
Also is it normal for immine mediated dogs get much iller in nightimr and morning?
She realy is very sick then
And thst hasnt changed
Today 15 th day of strong prednidale 37.5 Mr
And doxycycline
And antepsin n cimetidine
N she lying there abdomen inflamed v hot
Breathe laboured
She will pick up in the day likely but nights n morning a nightmare for her n me
She used to be so happy in the mornings
Now she looks at deaths door
I have been crying
:-(
My poor girl

[Angela]

Hi Christina,

Yes, the pred is normally split into two equal doses initially, morning & evening.
AIHA/IMHA is an autoimmune disease.

Has your vet had much experience with autoimmune diseases?  You need one that does & one that is willing to listen to you

Hugs

[Jo CIMDA]

Hi Angela

Do you have any blood figures? Can you find out what her last red blood cell reading is either HCT or PCV will be fine?

It does sound as if the preds are causing Holly to be so unwell and in my experience it does get worse at night especially if the weather is warm.  Perhaps a damp cloth placed over her would cool her off a bit and make her feel more comfortable.  Are you giving the Antepsin with the preds?  Antepsin should be given two hours after or before medication because it lines the stomach and it will inhibit the absorption of the drugs. Also I do wonder if Holly is a bit dehydrated.  Is she eating well?  She should be wanting to eat and drink a lot, if she is not then it is likely that the preds are beginning to be a problem and the only option is to reduce the dose and perhaps introduce another immunosuppressive drug.  If her HCT/PCV is in the upper 20% then a reduction in preds could prove to be the best action.
Good luck today.
Jo

[christina]

Thanks Angela and Jo for your replies
Holly at vet Thursday
Blood test revealed white cells normal
But red blood cells still low,still anaemic
Sorry I never got exact figures as vet was adament holly had be on prednidale 37.5mg once a day
As red cells still havent responded with one,week 25 mg
And 15 days 37.5 mg prednidale
Is prednidale same as the other prenisodole?
I asked if I could split the dose 12 hr apart
Vet said ..no
I was concerned asholly  so bad in the night wondered split dose helo
As pred in mornings
Vet said no
Also holly having shaking fits when pred is due amd for several hours,at a time
Seems like back spasms heart bidders it horrible
Shes also changed body shape
Bigger abdomen,smaller lower half torsu like shrunk in
Vet said steroid chAnge shape
And I have been saying for weeks maybe inflamatory bowel
Well wed morn she v ill
Thurs mien very very ill
Many poos ,blood mucus in poo
Vet checked bowel
Yes blood n mucus
I said she in terrible pain with it
Vet say holly not sore when they palpitAte abdomen
,ii said
Shes,in agony in the night
At 4 pm she stil hadnt eaten not even fresh salmon n rice!!!
Unheard of for holly
Vet try give pro kolin
I said doesnt help she need colitis meds
She
Said we cant as they interact with what she on
Cimetidine
I asked take of cimetidine n give flagyl as she needs help
Vet wanted to stop lyme med doxycycline as been two weeks
I said not happy with thEt as if holly got immune mediTed disease because of lyme
Doxy needs taken at least four weeks
Usualy eight though four at least
So holly
On antepsin twice a day
Doxy. N flagyl
Prednidale
Antepsin makes feel sick
So cut to twice a day
Misses cimetidine but vet keeping of even when stop flagyl
She has crawly noise throar at times
Gags feels sick
But has done

[Jo CIMDA]

Hi Christina

Are you in the UK?

Pednisolone and prednidale is the same - the generic name of the drug is prednisolone.  The whole reason for splitting the dose is to limit the gastric effect and this is usual practice.  The dog still gets the same amount in a 24hr period.  It is said that prednisolone given early in the morning maximises the effect because that is when the body's own cortisone levels are at the highest but that is no good if it causes stomach ulcers that may bleed and cause iron deficiency anaemia (not AIHA).  I have known many dogs to have bleeding stomach ulcers because of taking preds and have become anaemic as a result.

Holly may have a bacteria in her gut such as campylorbacter.  This can often be the case when the immune system is compromised due to steroids.  Perhaps a stool sample should be sent to the lab.

Did they not send off a blood sample to confirm she had Lyme disease? 

It does sounds as if the preds are causing Holly discomfort in her abdomen. 
Cimetidine can be changed to Ranitidine and this can be bought cheaply from a supermarket and also it is much kinder to the liver than Cimetidine. Ranitidine is used far more than Cimetidine these days.

Did your vet tell you the HCT or PCV figures?  Before I comment more I would like to know what the figures are. Aslo can your vet identify immune cells on the blood smear?

The anaemia, stomach problems, steroids dose etc., it doesn't 'fit'  and more information is needed.

Jo

[christina]

Thanks Jo
I adked vet if there was amother ant acid that didnt interact like cimetidine does with flagyl
But vet just said give antepsin
We are unfortunately working without a lot of test results apart from the blood tests n.scans abdomen n heart
Because I do not have the money for all the expensive tests
So vet had said if give lyme meds will know if helping etc
So it a guessing game as costs astronomical for sending things private testing outwith the practice
She has had stomach pain since she colapsed before the meds
I think possibly immune mediated colitis
Next blood test I will write down.her red blood levels
I wonder if I should split the pred dose even thouth vet say no
Will ask again vet
If ranitidine could be used instead of antepsin
Dont like antepsin not good for holly make feel sick
Shr still blood poo
And do use wet towel at night but temp always goes up
N.ill unable eat n move around in mornings
Its so hard
Im concerned we not geting to root of problem
And have heart problem.also
Incredibly stresful
My hope is that she can get healed from this
But its not lookin very good
Yet I guess white cells normal good
How long does it usualy take to get red blood cells up with pred?
Thank you for listening n.helping
X

[christina]

Hi Jo
In what way does the steroid dose not fit?
Holly has had inflamation n.fever ever since she collapsed
Pain in abdomen before steroid use
But never before the day she got ill
She had two xrays n.one ultrasound on abdomen
But vet cudnt see what causing the pain
Though spleen enlarged
Lymph nodes enlarged
Vet did needle biopsy on spleen
Lab said could be fungal protozoa infection
But not conclusive
Flagyl helps,with protozoa eg giardia
But she hasnt received any anti fungals as not conclusive
Thanks,again
Realy apreciate this website very much x

[christina]

Oh yes,and meant to ask
How do I check out the Michael j drug files thanks x

[Catherine]

Christina, is this what you mean? It is under "Topic: Auto Immune Haemolytic Anemia (AIHA) - start here." on the site. I have copied a bit for you:


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 base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

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!

[Catherine]

Have copied it all to save you looking - it may help:



(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. autoimmune (or immune mediated) destruction of the red blood cells occurring in the circulation of the blood (regenerative AIHA) or within the bone marrow (non-regenerative AIHA), tick borne diseases such as Lyme disease, cancers, parasites, poisoning (zinc, onions etc), a reaction to drug administration, hyperthermia, systemic disease. However, in the absence of an identified, underlying cause, the most common form of haemolytic anaemia is primary non-regenerative AIHA.

The life of a red blood cell is approximately 110-120 days. After this time the old red blood cells naturally leave the body and are replaced by young red blood cells, (reticulocytes).  Reticulocytes are formed in the bone marrow, and when they are ready they migrate to the circulation where they mature and then exit the body when their life span is complete.  It's a circle of life – as the old red blood cells die off new ones replace them.  This is a normal daily occurrence.

If this normal process is prevented from happening, as in the case of a dog with non-regenerative AIHA, where the dog's own immune system is producing antibodies which are destroying these young red cells in the bone marrow, eventually the dog will become anaemic.  This is a chronic form of AHIA.

The destruction of the red cells in the bone marrow starts some weeks before clinical signs appear and initially, the dog will cope quite well, as their body adjusts to the gradual effects of this form of anaemia.  However, eventually there will come a time when the lack of red blood cells in the circulation shows in various, external clinical signs.

Common, initial 'telltale' signs of chronic anaemia:
Your dog may have a craving to eat the earth or compost, or chew on concrete or bricks.  Another indicator could be bright orange coloured faeces and dark coloured urine (this is the blood pigment leaving the body). Your dog may become weak or lethargic, or even collapse for a few minutes through lack of oxygen to the brain, especially when excited. Take a look into your dog's mouth and see if the gums appear pale. If the red blood cell count is extremely low, the tongue and whites of the eyes may have a blue tint to them. Occasionally the dog's gums, skin and possibly whites of the eyes, will look yellow with jaundice. Other signs to consider include loss of appetite, high temperature, inexplicable limping and depression.  Consideration must be given to recent potential trigger factors such as hormone imbalance (recent season/whelping), vaccination, drugs, pesticides, flea treatments etc., also predisposing factors such as breed and age.

The family history of your dog is very relevant to any investigation, and can contribute towards achieving a diagnosis of an autoimmune disease. Dogs with a primary autoimmune disease have a genetic predisposition to one or several autoimmune diseases. Autoimmune disease runs in families so it is possible if one dog in a litter, or a relative, develops autoimmune disease the others may follow. 

Non-regenerative haemolytic anaemia is the most common form of primary AIHA but your vet should not assume this diagnosis. As stated previously, a dog can become anaemic for a variety of reasons and these will need to be investigated.  However, it appears some vets don't consider that AIHA can be a primary disease occurring in the bone marrow and very often a grim, incorrect diagnosis of leukaemia is given.  Blood testing and examination of a blood smear is vitally important to a diagnosis of AIHA. A bone marrow biopsy, though very intrusive, may give a firm diagnosis but sometimes a diagnosis of non-regenerative AIHA is achieved by elimination of other primary or secondary causes of anaemia.

Autoimmune disease is often a 'fight against time'.  If the red blood cells are below 12%, a blood transfusion is likely to be necessary to 'buy time' for the treatment to work.  The dog needs to be sustained through this early period of the disease. It is not necessary to have 'typed' donor blood for the first transfusion but subsequent transfusions need to be compatible therefore the recipients blood should be taken and sent away for blood typing before the first transfusion is given so that the type can be determined should another transfusion be necessary. Obviously, blood transfusions carry risks but they can also save lives. Early diagnosis and treatment may avoid this procedure. 

Once treatment has started, an increase in red blood cells will hopefully be seen in approximately 5 days (the time it takes for the reticulocytes to develop and migrate to the circulation). The level of reticulocytes seen in a normal blood smear is very low. When a dog is recovering from AIHA the levels should be very high and this reflects the level of anaemia.  Correct dosage and duration of treatment is absolutely crucial to a favourable outcome.

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 base on a dog receiving an induction dose of 1.0mg/kg/q12hrs

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!


WHAT TO EXPECT ONCE TREATMENT HAS STARTED

If a dog has a serious autoimmune disease, then the sooner treatment commences the better chance the dog has of survival.  The main delay to starting treatment is obtaining a diagnosis or at least your vet being sure that he hasn't missed anything that could be made worse by giving high doses of steroids.  Achieving a diagnosis can be a fight against time. 

If your vet has decided that in all probabilities your dog has an autoimmune disease, then to a certain extent, which autoimmune disease your dog has, as far as treatment is concerned, is irrelevant because with the exception of a few diseases, they are all treated the same, that is, with immunosuppressive drugs.  The main objective is to 'knock out' the immune system and virtually stop it from working (or near enough) so the destruction will cease and give the body a chance to recover.  As previously stated, this treatment regime works in most cases, that is, if it has been given early enough and the dosage is correct.  All dogs are different and some can tolerate the drugs better than others. In proportion to their size, small dogs seem more able to tolerate higher doses of steroids than large ones. Some diseases are more serious than others and carry a poorer prognosis. So the initial crisis is a crucial time, however anecdotal evidence shows that many more dogs survive than die if correct treatment is administered in good time.

It is hoped that a positive response can be seen within 4-6 hours of starting treatment (depending on the disease), but in a serious, life threatening situation, the first 2-7-14 days can be a very worrying time.  Assuming the dog has stabilised he will quickly feel much better, and if he is in hospital may be allowed home within a week.

When he comes home he will probably have a 'goody bag' full of drugs.  He will be on a high dose of steroid, usually prednisolone, and he may also be on another immunosuppressive drug, such as Azathioprine.  Your dog will be weaned off in a controlled manner according to his wellness and clinical observations. 

Note: High doses of steroids must not be stopped abruptly.  Your dog could go into an adrenal crisis if the medication is withdrawn too quickly. 

In addition to immunosuppressive drugs he should have something to protect his stomach from excess acid.  The last thing your dog needs when he is feeling poorly is a bleeding stomach ulcer caused by the drugs.  Sometimes, Antepsin is given to coat and protect the stomach (but this must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed).  Zantac (Ranitidine) may also be prescribed to take away the excess acid. Zantac does not inhibit the absorption of the drugs. Another gastroprotectant used is omeprazol. To minimise irritation to the stomach it is usual for the daily dose of steroid to be split into two doses and given with food, one dose in the morning with breakfast and the other dose with his evening meal. I have known several dogs, who did not receive a gastroprotectant as a part of their treatment regime, who went on to develop anaemia. This is not autoimmune haemolytic anaemia but iron deficiency anaemia caused by bleeding stomach ulcers. Using a gastroprotectant is a good preventative measure. When the steroids have been significantly reduced to a low dose, a gastroprotectant may not be necessary.

Excess acid produced because of the drugs may make a dog prone to developing pancreatitis. A dog with pancreatitis will appear in pain and his back may be arched as if he can't straighten up.  He may be lethargic, seem bloated and have a tender abdomen. Dogs usually go off food and water, may vomit and look depressed.  If you suspect that your dog has pancreatitis, don't try to feed him because it will make the condition worse. Take him to the vet as soon as possible as he may require treatment or need to go on an intravenous drip to stop him dehydrating.  Again, the risk of pancreatitis should be minimal once the dog is on a lower dose of steroids.   A low fat diet is best when your dog is on high dose steroids or prone to pancreatitis. 

As your dog's immune system is being significantly suppressed, he will be more likely to pick up infections, and will not have the ability to fight against them.  As a precaution a broad spectrum antibiotic is often prescribed. Also it is sensible not to exercise him in areas where he is more likely to encounter infections, for example, a park or a popular dog walking area. 

Whilst your dog is on high dose steroids he will want to eat and drink excessively. However, this also means that he will want to urinate more and this can sometimes cause temporary incontinence.  You may have to get up to let him out during the night and if you leave the garden door open during the day, it may save some mopping up!  He cannot help it and won't like it either, so don't be too hard on him, it's only temporary. You will notice as he is weaned off the drugs the unwanted side effects will subside and he should return to normal habits and behaviour.  Urinary tract infections and/or bacterial skin pustules are not uncommon when a dog's immune system is suppressed, and this is often the reason for a dog to be off colour during this time.  Note: Always consider a urine infection if your dog seems under par.  A course of antibiotics will usually sort this out quickly.

Depending on what autoimmune disease your dog has, he will probably need to have regular blood tests.  Biochemical blood tests will also keep an eye on other body functions, such as those of the liver and kidneys, which is important at this stage.

Assuming good progress is being made, the clinical signs of his illness are diminishing and positive signs of improvement are apparent, your vet will want to start weaning him down from the high doses of steroid.  This process can take 3-6 months or more, and usually begins anytime after 10 - 28 days from the start of treatment, depending on the results of his blood tests and his clinical signs.
Relapses are not uncommon, especially in diseases that are difficult to control, for example SLE.  A relapse may mean that initially, your dog needed to be on a higher dose of immunosuppressive drugs for a longer period of time, or your dog may have been weaned off a little too quickly and then the dose withdrawn too soon.

If a relapse occurs he will probably show similar clinical signs to his initial crisis.  He will have to go back on an immunosuppressive dose of prednisolone, but it may not have to be quite as high as before. A combination drug may need to be added at this stage. The weaning process will then have to start all over again. Returning to an immunosuppressive dose will mean that he has to go back on a gastroprotectant.

[christina]

Thank youbonniemist
Very helpful!:-)x

[christina]

Hi everybody
Holly has got a bit brighter in herself since I changed pred to two doses a day
Vet didnt agree with this
But I listened,to folk on here and it does,help x
As well as the flagyl helping her intestinal pain
Still sore n fragile but brighter
Apart from got a scratch from a cat yestrday n it quite a big wound
Top layer skin away
Round circle n wound underneath
Keeping eye on it
Its deep
Gave baytril antibiotic as well as her flagyl n doxycycline n pred
Concerned it dangerous,as immune system low with pred
So keep eye on
If not feel much beter tmoro will have take vet
Must be cat claw got her
Any recommendation help heal wounds?
Thanks
Apart from that good that her energy up!:-)x

[gschellinger]

Hi Christina,
I don't post very much but have been reading your posts about your Holly. If you can get Manuka honey to put on the wound it may take care of any infection. It is a great product, good for so many things.

Best wishes for Holly and you. I'm glad you listened to Jo and Penel and split her dose of pred.
gail

[Jo CIMDA]

Hi Christina

Wound healing is difficult when a dog is on immunosuppressive doses of steroids but you are giving antibiotics, and as Gail says you could try Manuka honey.  Glad she is a little brighter.

jo

[christina]

Thank you gail and Jo x
Yes im realy glad Jo and penel told me about splitting pred
As I say my vet said ...no
But I went ahead n she hasnt been shaking for hours since I did that
Thank you for this website and all the work that is put in to help little dogs like holly
You know I love her so very dearly!!!
Will get some manuka honey gail
She had it before internaly to help heart
But going vet today because we havr ben through so much that I dont want her to get infected
Vet didnt take bloods
Just leaving on 37.5 my pred a day
For amother while
But I give homeopathy to try offset side effects
Oh tis never ending being Florence woofingale for all us caring for our sick dogs!x