Thrombocytopenia

[Alison68]

Hi jo,  bella's blood platelets are still ok and she's been taking one steroid every fourth day for a while my vet said yesterday her blood test came back ok and what would I like to do next either stay as we are or try stopping completely.  I did say to take a gamble and stop for a month and then check her blood because if we don't try we want known.  But now I'm not sure if if I would be doing the right thing because of bella's previous history of going to low on the steroids and she relapsed in December 2014 . Her liver enzymes are still high and still at the same level as last month

[Catherine]

How high is high for the liver enzymes - do you have the figures for ALT, ALKP and GGT? Is her Cholesterol result elevated? Just a thought but has she any symptoms of Hypothyroidism?  I have found that sometimes the ALT and GGT can be elevating when the dog is HypoT and then when it was given thyroid medication the ALT and GGT started to return to normal values.

[Alison68]

I don't know the levels,  don't know about cholesterol I don't think that's been done. She's has acquired liver shunts not sure if steroids caused the shunts or the imuran that she was on for a few months. I'm just not sure if I should stop her steroids or continue with them permanent . It's just a bit of a worry about stopping and if she'll relapse because she's good now and she could end up back on high dose of steroids

[Jo CIMDA]

Hi

5mg of prednisolone every three days is such a small dose, it is like a flip of a coin whether you should leave it off altogether or continue.

My own thought are this dose will not do her any harm.  This dose will not stop a relapse if she meets an appropriate trigger but what it may do, as she has been on steroids for a while, is maintain homoeostasis,  and that is not to be sniffed at.

When the dose is so low the permutations for dosing are numerous.  Her are a few options to consider.

One option is to give her 5mg pred every fourth day for a month and then every fifth day etc.,  until she is on one a week.  You can then decide whether you want her to remain on 5mg pred a week or stop it altogether.

Another option is to reduce the dose to 2.5mg for about one month or more, and then leave it off altogether.

Another option is to get some 1mg prednisolone tablets and gradually over a period of months reduce the dose by 1mg at a time.

I have known dogs to have been on all these options and none are wrong.

You must give more time for her liver values to return to normal. Unless they are very high this isn't usually a problem. 

You have lots of time to think about this as there is no hurry to do anything. I feel you will give it a lot of thought and come up with the protocol that will best suit Bella.

I know how anxious you are but you have to allow yourself to believe it is a great stage to be at.

Jo

[Alison68]

Thanks jo, she's been on steroid every fourth day for a month, all I been told is her liver enzymes are very high and have been for months now but aren't getting any higher . In December 2014 we went down to 2.5mg every other day and then in 2 weeks her platelets were really low and then ended back on 4 steroids a day. Which gave her the skin condition that she had in April last year and we had to get her down quickly on the steroids to reverse the calcium deposits . That's why I don't want her to end up on hgh dose  again because she'll get calcium deposits back . I think I should keep her on low steroid dose . I'lltalk to my vet Monday and tell her

[Jo CIMDA]

Hi
Have you considered introducing Melatonin to Bella's regime?  Look at these links.

http://www.ncbi.nlm.nih.gov/pubmed/12424512


http://www.ncbi.nlm.nih.gov/pubmed/9066251

Also, one of our members has kindly written her account of using Melatonin (see below).  Personally I would give Melatonin a try if I had a dog like Bella.  What have you got to lose?  Also, perhaps Bella would benefit from the use of Milk Thistle and SAMe etc., for liver support.

Jo



Our Personal Use of Melatonin by DW
« on: December 19, 2015, 12:52:31 PM »

   

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

[Alison68]

Bella's on samylin for liver support she's been on it for months . I've decided to drop the steroid  to one every fith day and see hhow it goes. I think it would be good if she could come off steroids. The vet is quite surprised on how bella is looking considering she has a few acquired shunts because she's a picture of health and looks fantastic

[Jo CIMDA]

That seems like a good plan.  It is always so uplifting when the vet is pleased with their progress.

Good luck
Jo

[Alison68]

Bella's been off the steroids for 8 weeks and her platelets are ok, her liver enzymes are higher on this week's test and she's lost some weight.  She lost 1.2kg in five weeks it's due to her not eating enough because some days she's fussy with her food. She's getting up at least once during the night to go for a pee she doesn't have an infection because a sample was checked in the lab last week.  She did have a urine infection a few weeks back and it cleared up

[Jo CIMDA]

Hi

I wonder why Bella's liver enzymes are higher this week when she has been off steroids for so long?  It is usually the other way around.

It is such a shame she has lost so much weight.  Was she fussy with her food prior to her being on steroids?  Have you tried changing her diet to tempt her to eat?

I presume the vet did a full biochemical blood test which showed that her liver enzymes her high. Was there anything else that showed up on the test?

Is she drinking more during the day, which might cause her to have to get up in the night?

Jo

 

[Alison68]

I was thinking perhaps her liver is getting worse due to the aquired shunts and that is why her liver enzymes are higher.  She isn't drinking excessively and her needing to get up through the night started when she had an infection and it cleared up with antibiotics but she still needs to get up to pee  in the night.  I was explaining to susie Monday that two years ago bella was not eating properly and lost weight  and also needing to get up through the night to pee and I had brought her in and the vet found nothing wrong with her but a few weeks later she had thrombocytopenia.  About her eating she usually tells me when she wants food because she'll go in the kitchen and bark for food

[Jo CIMDA]

Hi

I do hope a relapse isn't looming.  You will be well prepared if she does, and watching her like a hawk, I expect.

Fingers crossed

Jo

[Alison68]

Definitely watching her like an hawk. Got vet's on the 4th April to check her weight and probably her blood . I'll let you know how things go .

[Alison68]

Hi , bella had her vet visit on Monday and she lost more weight she was 11.1kg . Took a urine sample and the vet dip tested it and there was aquite a lot of blood in so it was sent to the lab for testing and bella was put on antibiotics . The results were back today and there was no sign of infection but she said it was +4 blood in it so I've got to take her in tomorrow to do her blood  to check platelets and we might have to scan her soon to see what's going on in her bladder. She used to be 12.8kg and she's now 11.1kg . I'll let you know next week when her platelet count comes back

[Jo CIMDA]

Fingers crossed for today.

Jo