AIHA Relapse

[Highbank]

Hi

We have a 4 year old Beardie bitch who was diagnosed with  AIHA March. Started on a high dose of prednisolone  and a blood transfusion. Was being weaned off as pcv going up(up to 41%). Steroids down to 5mg every 3rd day and then pcv started to drop, down to 35%. Vet put her back to 30mg twice a day , on that for 12 days and now dropped to 29% . Wants to retest Monday as only back on for 12 days. Getting worried as steroids don't appear to be working . Is this typical of a relapse or is there anything else we can do.

David

[Catherine]

What does your Beardie weigh and how much Prednisolone was she started on originally? (A dog weighing 20kg for example should have been started on 20mg of Preds. twice a day) The medication then should have been reduced slowly only when the PCV was going up. It sounds like maybe the dosage was not enough and it was reduced too quickly. Here is the dosing protocol I have copied from this site:

>>>>>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!<<<<

As it says a gastroprotectant is very important to protect the stomach.

Also, with my own experience with a dog with AIHA, I would say reduce slowly (if the dog is coping with the medication okay) and have regular blood tests - every few days, then weekly if the PCV is going up okay then every few weeks when it is stable. Also have biochemistry tests to keep an eye on the kidneys etc. If you have the regular blood tests then you can see well in advance if the PCV is dropping and not have to keep increasing to high dosing levels.

When did you have the last blood test for her? I would not wait until Monday.

You might want to add Azathioprine as well although that will take a few weeks to work. (25mg Azathioprine a day for a 20kg dog as a rough guide).

There is more information here: http://cimda.co.uk/smf/index.php/topic,11.0.html

There is hope but your dog must be on the correct dosage and not reduce too soon. My dog survived AIHA but we went very slowly with the reduction and had lots of blood tests.

[Jo CIMDA]

Hi David and welcome

I am sorry your beardie has AIHA.

Catherine has posted the best immunosuppressive drug protocol I have come across and it can be confidently used as a guide.

I am concerned that she is on 60mg pred a day and for a beardie bitch that is too much. Generally, 1mg/kg/12 hours is the maximum dose, unless there are other very unusual circumstances.  Any more than 1mg/kg/12hrs will not give greater immunosuppression and will only cause significant side effects which is detrimental.

Is she on a gastroprotectant to protect her stomach from the effects of the steroids?  Sometimes a gastric ulcer can develop as a result of steroid use and this can bleed which causes regenerative anaemia.  Often this is wrongly mistaken for a relapse of the AIHA.  Did she have non-regenerative anaemia in the first place - and is her current anaemia regenerative or non-regenerative?  It makes a difference.  Regenerative anaemia is more likely to be caused by another problem and which is secondary to the anaemia.

How is she coping with the effects of the steroids?  Does she have any other clinical signs?  Sometimes beardies with Addison's disease are first diagnosed with non-regenerative AIHA. It is unlikely but a consideration.

Also, sometimes if the steroids dose is very high it can suppress bone marrow production which will cause moderate anaemia. 

Sorry for all the questions.

Jo

[Highbank]

Thanks for the replies.

sShe weighs in at 26.1 kg and also currently is taking Zantac.

Originally started at 40mg twice a day (20/3/17) , and had a transfusion same time as pcv was 13% . We had blood tests every two weeks and only reducing if pcv had gone up. As pcv was going up dosage was then was reduced  by 25% each time .

Thought we were going well(5mg once every 3rd day) , Two weeks ago yesterday dropped to 35% so back up to 30mg twice a day . Yesterday it dropped to 29% , another blood test due on Monday and hoping an improvement.

We think it is the non-regenerative ( one that does not get jaundice) if that helps .

Thanks again

David

[Jo CIMDA]

She is a big girl David - I had a beardie girl like yours and she was adorable.

Non-regenerative is the usual kind of AIHA but I was just concerned that this time it might be regenerative caused by a stomach ulcer but if she is on a gastroprotectant then I doubt that very much.

She has done very well but relapses aren't uncommon.  Has she recently had anything that might have triggered a relapse such as a vaccine, worming drugs, spot-on, season etc......?  As it is non-regenerative it could be that she hadn't reached full remission and as the preds were lowered the aberrant immune system became active again.

She responded well last time so one would expected her to have responded this time, and because there has been a drop in PCV since starting this current treatment, then one has to question if this higher than usual dose is of any benefit, and it might even be contributing to the lower PCV, and it will certainly be contributing to side effects.   It is not doing what it should be, so one has to think again and the most obvious thing to do is to lower the dose and perhaps add another drug like Azathioprine.  More isn't always best.  What does your vet say about this?  Azathioprine will enable you to lower the dose of preds quicker and still maintain good immunosuppression.   

I have known the PCV to plateau at high doses and not to increase again until the dose is lowered.

How is she in herself? Watch out for signs that the preds might be overwhelming her.  You can see the info in the files about what to expect when treatment has started.

As mentioned in my previous post, the other possibility is Addison's disease.  Dogs with Addison's disease, who present initially with non-regenerative AIHA, are subsequently diagnosed with Addison's because they do not respond to immunosuppressive therapy. It is a long shot but it is something that your vet should be aware of.  Is it possible for you to take her to see a specialist for a second opinion?

I fully appreciate your concern.  I have been through it and one never forgets.

Jo

[Highbank]

Hi Again

Update on our beardie , blood test last Monday and PCV went from 29% to 32% so good news. Going again tomorrow for another test and hopefully if better will see about a reduction in steroids . Have asked about using Azathioprine also . will keep you posted.

And definitely slower reduction this time .

Regards

David

[Jo CIMDA]

That's great news David.

Although a slower reduction, similar to the Michael J Day protocol, seems to achieve better long term results, I am concerned that your girl is on a very high dose to start with - too high - and this can become a bigger and more dangerous problem than the autoimmune disease. 

If she is still on a very high dose (more than 1mg/kg/12hours) then it would be prudent to reduce the steroids to at least that dose, and a little more, and then start to reduce using the M J Day immunosuppressive drug reducing protocol as a guide.

She has done remarkably well and it is clear that her bone marrow can respond  but you don't want the steroids to do more harm than good. Beardies can be very strong and they don't give up easily, but they can be very stoical, so watch for any clinical signs that suggest the steroids are becoming too much for her.   All the information is in the files.

As she has been on such high doses of steroids, introducing another immunosuppressive drug is a pretty good idea.  It will enable you to lower the steroids, and reduce the side effects, and still maintain a good level of immunosuppression. 

The choice of drugs and the regimen is crucial to the outcome when treating an inflammatory AI disease.

Jo

[Highbank]

Hi Jo

More good news , PCV is now 36% . Steroids are now being reduced to 25mg every 12 hours . Is it still worth asking about replacing some of the steroids dosage with another immunosuppressive drug? .

Regards

David

[Jo CIMDA]

Thank goodness they are being reduced - and great news.

A combination drug such as Azathioprine is still a good idea because she has been on very high doses of preds and if the side effects become intolerable and you have a back up of say, Azathioprine, then you are able to reduce the preds which in turn reduces the side effects and still maintain a good level of immunosuppression.  It is a common combination immunosuppressive treatment.

There is no harm in asking your vet about it.

Jo

[Highbank]

Hi all

Update on our Beardie , blood test today and PCV still at 36% so neither up or down. The vet has now reduced the steroids to 20mg every 12 twelve hours so think going the right way . Still just using just preds but keeping other drugs in mind.

Regards

David

[Jo CIMDA]

Hi David

That is very good news.  The PCV might plateau around this number until you lower the pred dose again.   When a dog has been on such high doses of preds it can affect bone marrow production. If this is the case, as the preds are lowered the PCV is seen to rise, so I hope as the dose continues to be reduced you will see improvement.

I hope she is coping with the preds.

Thanks for the update.

Jo

[Highbank]

Hi all

Further update on our Beardie, tested again on 1st Sept and PCV was 39%, next test was 14th Sept and if same was going to reduce preds from 20mg every 12 hrs BUT PCV went down to 35%.

Off to vet tomorrow to discuss options,  referral and / or using Azathioprine as a replacement for some of the press. We think she is suffering from side effects now , obviously hair loss, think now some issue with back legs, loss of power and tiring more easily now in the last few weeks. Think some sores on the feet .

Hopefully the vet can help .

Regards

David   

[Jo CIMDA]

Hi David

35% PCV would not be a problem for me considering she has been on high doses of preds for so long.  The side effects of the preds that you are seeing should not be ignored and the slight drop in PCV won't be as a result of an immune destruction of the bone marrow because the dose of preds she is on is sufficiently suppressing her immune cells to render them useless, so they cannot be destroying the immature red cells in the bone marrow. So the most likely cause of the slight drop in PCV is the prednisolone is actually inhibiting bone marrow production.  This can happen when a dog has been on high doses of prednisolone for many weeks.  Another reason for a drop in PCV is she may have developed a stomach ulcer which is bleeding and this will cause regenerative anaemia.  Do you know what her reticulocyte count is?  Reticulocytes are immature red blood cells.

Everything you describe, even the sore skin on the feet,  indicates classic signs of chronic and severe drug induced Cushing's and this must not be ignored because it can be life threatening.   The problem you have at this moment in time is the side effects of the drugs and not the level of PCV or the AI disease.  Address the side effects by significantly reducing the preds and the PCV should start to rise after a little time and certainly within a couple of days you will see a positive difference in her. You need to allow the body to return to normal function and on this dose of preds it never will.  You can help the feet by giving evening primrose oil and fish oil and Natural Vitamin E.  You can even put Natural Vit E onto the sores to give some relief.

This scenario is common when a vet leaves the dog on the wrong drug protocol and continues to give high doses of preds.  Look at the clinical signs of your girl, and not the numbers, and deal with the problem that you can see. Believe your eyes.

If your vet is not open to this, then please get a referral as soon as possible.

Good luck today
Jo

[Catherine]

I know all dogs are different but I am not sure what medication protocol your vet is working too. I do not have all the details but from what you have said it sounds like your Beardie has been on this second round of treatment since about July when you were weaning her off the Preds. If so, then this time it sounds like your vet has kept her on a high dose too long. My AIHA dog started with 9 Preds  a day (a total of 45mg) and 25mg of Azathioprine. Two months later (which I am assuming is about the same time as your dog has been on them this time) she was on 5 Preds (and the Azathioprine still). Her PCV was 41%.

Have you had a biochemistry test on her to check her kidneys, liver etc.?

The loss of coat, muscle, leg strength etc. is the side effects of the Preds but you do have to watch out that she does not suffer with more serious complications.

It is not a significant drop in PCV but if I was you I would have her PCV tested again today before you decide anything. It may be that it will have increased.

[Highbank]

Hi all

Just providing an update on our Beardie Blossom.

We persuaded the vet to add Azathioprine , one every other day , so thanks for that , was your suggestion..

We started to reduce preds and Vet checked PCV every two week from end of October and happy with the results . 

Her PCV finally started to rise and went to 44% in January and preds were being reduced from then on - slowly . She is now off preds , for last 6 weeks and Azathioprine reduced to one every three days . If still ok end of this month then reduced to zero. Fingers crossed for her.

We are very grateful for all your help and advice and Blossom the most grateful of all.

Thanks again.

Regards

David