Sadie's Story - Immune Mediated Thrombocytopedia

[goldenhamster]

Wanted to share my story for others who just found out their dog was diagnosed with immune mediated thrombocytopedia.  As you are probably doing, I immediately searched the internet for any information I could find.  I kept reading of worst case scenarios, despite the survival rate being 85-90%.  So I thought it would be helpful to hear of an experience on the other end.

My 8 yr old Havanese, Sadie, was diagnosed about three months ago with this disorder.  I had been noticing some slight bruising on her back a few months prior, but didn't really pay much attention to it as she had been rolling around on her back a lot recently.  The night before I was going to leave on vacation, Sadie started vomiting profusely.  What was particularly unusual about it was that it was several times throughout the night so it didn't seem due to something she ingested (in which case vomiting would have provided some relief).  While giving her a bath the next morning, I noticed very slight marks on her stomach and a pretty significant bruise below her chin.  Otherwise, she seemed in pretty good condition, with normal energy levels.   I went to the vet emergency room the next morning as a precaution.  They took her blood, and her platelet level was at 20K (normal is around 200K).  i believe around 20-30K is when you can start to get internal bleeding.  So they told me to cancel my vacation and they immediately put her on 10 mg of prednisone a day (she is 14 lbs).

As expected, the prednisone caused a lot of side effects - mostly excessive drinking of water/eating, lethargy, and somewhat of a change in personality (less affectionate).  Lots of peeing everywhere and anywhere in the house.  She typically sleeps on my bed, and she started sleeping on the floor, I think, because she didn't want to pee in the bed! 

The vet had me come back every 2 weeks to get her blood platelet count rechecked.  After the first week, her numbers were back to over 200K (i.e., within normal range) but her white blood cell count was elevated and she had developed a skin infection.  So they put her on antibiotics too and reduced the prednisone to 7.5 mb a day.  Apparently the higher white blood cell count is pretty typical of a dog fighting this disorder.  Since then, every 2 weeks they have reduced her prednisone.  She's currently at 2.5 mg every other day and seems back to normal.  Her platelet count is at the high end of normal and she's back to her old self several weeks after this started. 

The vet warned me that sometimes what appears to be canine immune mediated disorder is actually cancer.  However, given her rapid recovery, the vet didn't think that was likely here.

In terms of what triggered it, my guess is it was a combination of vaccines and lawn pesticides that people use.   About two months before the incident, she had been exposed to a bat and the CDC recommended she get a second rabies shot just to be sure.  I also take my dogs on long walks during the summer, and a lot of people use lawn pesticides.  I suspect the combination of both things was the trigger.

There are two other people at my work whose dogs are going through the same thing right now - these other two dogs are also around 8-9 years old but all different breeds.  All three dogs have survived, but some have had a lot worst side effects with both the disorder and reactions to the prednisone and have taken a lot longer to recover.  For instance, one dog went temporarily lame and had significant hair loss on prednisone, in addition to the earlier side effects I mentioned.

The whole incident has made me very cautious now about what shots they get as well as walking on other people's lawns. I intend to minimize her vaccinations from now on and will have to keep an eye out for a relapse. 

Not a fun thing to go through but do realize that many dogs do survive this disease with proper, timely treatment.  And be careful of vaccinations and environmental toxins!

[Jo CIMDA]

Hi and thank you for sharing your story about Sadie and this horrible immune mediated disease.  It is so helpful to others who are going through this.  You are very lucky to have a vet who knew what to to and how to reduced the steroids and I am so pleased it ha worked for Sadie and she is doing well.

You are right to limit potential trigger factors and it is likely that certain vaccines (especially those that are live vaccines) are not necessary.  Perhaps you could have an antibody titre test to confirm protective immunity.

Prednisolone can cause so many different side effects.  Individual dogs, and different breeds of dog, may respond differently too.  Some breeds of dog eg., bearded collies,  lose a lot of their hair and yet a breed like a Jack Russell, for example, the hair loss might not be noticeable. The Hair does grow back but sometimes it can take 6-9 months.  Smaller dogs generally cope better with high doses of prednisolone than larger dogs, so it very much depends on the individual and also the dosage and duration of drugs. 

Thanks again for sharing this good news.

Jo

[goldenhamster]

Just a follow-up...  it's end of December 2015, and Sadie just had her first relapse.  What is particularly scary is how QUICKLY it happened.  She had just gotten blood work taken about a month ago, and had normal blood platelet levels.  Then this week, when I took her to the groomers, they noticed she had some spotting in her ear and thought it was an allergy.  I then noticed a little on her stomach.  Had she not had previously diagnosed with immune mediated thrombocytopedia, I would have dismissed it.  However, given her history, I immediately took her to the vet and found out her platelets were at 8K (normally should be 200K).  Although they put her on prednisone as a precaution even before bloodwork came back, she started to get bruising the first day on her stomach and legs, despite little physical activity.  Fortunately, she responds quite well to prednisone, so vet and I are hopeful.  However, it's a cautionary tale that you  need to constantly check for bruising on your dog once diagnosed with immune mediated thrombocytopedia, as a relapse can occur quite quickly and can easily be mistaken for other problems. Even bloodwork done every few months might not be up to date.  What is also scary is that at least with my dog, there are no obvious symptoms that anything is wrong until the platelets are extremely low and I see bruising (i.e., she has normal appetite, weight, energy level).  This makes it impossible to catch it early.  I have her blood checked every six months, no longer have her vaccinated, and avoid lawn pesticides, and she still had a relapse.

[Jo CIMDA]

Hi

I'm sorry Sadie has had a relapse.  It is very difficult to find out the specific trigger but if a dog is in remission one thing for sure is something has triggered a relapse.  The problem is we can't protect our dogs from every potential trigger because something as common as  stress can trigger AI disease.

It is typical for a dog with IMTP to appear very well even when the platelets are extremely low and some vets do not respond as they should to a dog showing such low platelets.  You are so lucky to have a vet who responds to what he sees in front of him and like you say Sadie responds well to the preds.  Recently Harley's owner wrote about the benefits of introducing Melatonin to the drug regimen.  You might consider having a chat with your vet about this.

IMTP is scary but thank goodness you acted promptly.

Best wishes

Jo

[Jo CIMDA]

I've posted this again to save you doing a search.

Melatonin

I think I probably need to briefly say what meds we have been on/tried with Harley, for those that haven't been with the Group as long.
We are currently going through our 3rd attempt to regulate his  platelets and have tried different protocols each time.   This time, I have insisted staying close to Prof. Day's protocol but taking it even slower on the lower end of reduction.

He was diagnosed with IMTP 4 years ago.   His first blood count was 30 when diagnosed and he was given an immediate I.S. Dose of Preds (1mg/kg/12hr).  Follow up bloods a few days later saw a healthy increase in platelets so we knew he was steroid responsive.
However, we failed to achieve remission as Harley's platelets dropped as soon as we reduced the Preds to around the 10mg daily stage.
We embarked on the 2nd attempt, increasing the Preds to the I.S. Dose again.  This was such a blow, as one of the side-effects with Harley was significant muscle wastage and he had just started to recover and gain a little muscle-mass when we had to increase the meds.   He lost all that was gained and some.
His liver enzymes were very high but I was told to expect this and we started on Milk Thistle to help this.
When the 2nd attempt failed, despite increasing the Azathioprine, Atopica was suggested but personally I resisted using  this drug.   We asked to be referred to Cambridge and though we tried various regimes to regulate Harley's platelets, we failed and I had no other choice than to 'try' Atopica (I saw it as a last ditch attempt.   Even spleenectomy was considered but I had decided that I wouldn't be prepared to consider this).     Atopica was given at high doses but sadly, at the end of 6 weeks,  his platelets dropped to an all time low of  20, despite remaining on 5mg Preds as well.

The only thing left was to again, put Harley on a much higher dose of Preds for the 3rd time but the Vet at Cambridge wasn't happy to prescribe the I.S. Dose of 1mg/kg/12hr – instead we halved this and gave 30mg daily plus the Azathioprine.    We hoped that his platelets would rise but not necessarily as rapidly as we had seen initially, when he was on a higher dose.   This seemed to work and Harley's platelets started to rise slowly.
We discussed the possibility that Harley may have to remain on quite high doses of steroids and we would have to accept the long-term risks that followed.
About 6 weeks in,  I was asked if I would be happy trying a drug that my vet had heard was being used with some success in the treatment of IMTP in America,  where it was used alongside steroids or sometimes on it's own.

We give 6mg/12hr.  I use slow-release version and they are a prescription drug in the U.K.
The downside is that they are expensive.
In the States however, you can buy Melatonin over the counter at Health Food shops and I gather, this is what they tend to use.
At the moment, things have been so volatile with Harley, I am not prepared to take the risk of 'trying' the over-the-counter version but may consider it in the future.  They cost a fraction of the price.

Long-term side effects?    I have been unable to find documented feed-back but short-term, they seem to be tolerated well.   Certainly, I have not seen any side-effects.
We had Harley's bloods done yesterday and his platelet count was   364 and he is currently taking 4.omg Preds daily and 50mg Azathioprine EOD plus the Melatonin.
The hope is that we will continue to drop the Preds  *(and I have already mentioned that by my own choice – with the backing of my Vet though – I have decided to drop the Preds very very slowly at this stage) and then, we will start to reduce the Aza's -  then and only then, will we know if the Melatonin works!

* Next stage for us......to reduce the preds from 4.0mg daily   to alternate days of 4.0mg and 3.5mg for two weeks and then down to 3.5mg daily.

Hope this helps others.

Gwyneth