IMHA - weaning off meds...

Re: IMHA - weaning off meds...

Virginia Campbell — Mon, 29 Jul 2013 23:20:36 GMT

[quote user="GrooveJet"]PCV has never recovered above 24% [/quote]

[quote user="GrooveJet"]8 year old cocker[/quote]

See my cautionary tale in cyclopsorin IMHA thread. Think others have given good advice about finding out if haemolysis still occuring. If so, why? I hope for dog's sake that the answer is something fixable not "because it's a cocker"

Re: IMHA - weaning off meds...

Andrew Kent — Thu, 25 Jul 2013 14:28:09 GMT

Chronic GI blood loss would certainly be a consideration in this case. There is no benefit in giving dogs more than about 2mg/kg per day of prednisolone as the immunosuppressive effect is no greater but the rate of adverse effect is higher. So I would reduce this dose and consider some gastroprotectant medication.

Any history of travel or ticks? May be another consideration and can get a partial response to immunosuppression in infectious cases. Either test for this or give 3 weeks of doxycycline.

Any further problems with the pancreatitis? Azathioprine has been associated with acute pancreatitis in dogs so may need to be a bit careful and/or consider other immunosuppressive drugs.

I think Chris's idea of an external haematology is a good one to try to characterise this anaemia a bit better. What was the morphology of the red cells at diagnosis? Was there a spherocytosis? What has the regeneration done?

In answer to your weaning I would start dropping this prednisolone now and be prepared with other drugs if the PCV drops. I would half the steroid dose now, youve got azathioprine on board so the dog is well immunosuppressed. But as you say the dog doesn't sound classic.

Keep us posted!

Andy

Re: IMHA - weaning off meds...

Christopher Saul — Thu, 25 Jul 2013 12:50:34 GMT

Sorry I'm at work so haven't time to do a long answer right now, will try to later on....

Assuming you've ruled out primary causes of the IMHA and this is a primary, then the potential causes for a lack of response would include :-

-ongoing haemolysis

-inadequate regeneration - this can be seen if the immune attack shifts to erythroid precursors as well as for other reasons......

-low grade GI blood loss..... I have seen this in dogs with high doses of steroids.

I would suggest a reference lab full blood count/smear + reticulocytes (via NMB stain) - it would be handy to get an idea of how regenerative the anaemia is, if there's any sign of ongoing peripheral haemolysis or if there's any microcytosis or other evidence of iron deficiency,

might be worth thinking of doing a faecal occult blood too....

Hope this helps

Chris

Re: IMHA - weaning off meds...

Miriam Lodewyks — Thu, 25 Jul 2013 12:37:21 GMT

History is a little long and complex, but started with pancreatitis, then mild anaemia (20%) with low platelets (117). Stable for a few days then platelets dropped to 17!!! PCV remained alright for a few days, then plummeted to 13% = blood transfusion (luckily had had time to Type). Abdomen seemed rotund, but was scanned repeatedly and nothing unusual found (spleen and liver normal, no fluid). Coombs test negative, Baermann negative. PTT and PT remained normal (phew!).

Started her on 5mg/kg prednisolone (we're panicking at this stage) but a few days later PCV begins to drop again, so we add in 25mg aza per day. Finally she remains stable, though PCV keeps hanging around the 22-24% mark. All other haem normal.

By this time we've run out of insurance money, so now we're trying to just keep her stable and alive without doing willy-nilly tests. Haven't re-scanned her recently as owners have ruled out surgical intervention now anyway.

I am worried about this case, and I know I've missed something, but budget now restricted, and let's face it, she's still alive against all odds. I mostly want to know how and when to reduce med: she's now on 2.5mg/kg/day Pred and 25mg/day azathioprine.

Re: IMHA - weaning off meds...

Christopher Saul — Thu, 25 Jul 2013 11:51:11 GMT

Andy beat me to it but... What he said

Re: IMHA - weaning off meds...

Andrew Kent — Thu, 25 Jul 2013 10:31:08 GMT

I would be worried about weaning this dog off when you have only got the PCV to 24%. Hs it ever been higher? It implies low grade haemolysis may still be occurring or the regenerative response may have stalled so weaning down now a relapse would seem likely. Alternatively there could be another reason for the anaemia, for example chronic haemorrhage.

what were the PCV and platelet count when first diagnosed and what investigations did the dog have?

what dose of pred and apathioprine did you start with and where are you with each now?

what does the red cell morphology now look like and what did it look like to start with? What is the reticulocyte count? Was it 'classic' for immune mediated disease?

personally I would start by reviewing the diagnosis and then if you are sure think about additional immunosuppression.

in answer to the question about weaning I would wean the pred down by 25% every 4 weeks and then wean down the apathioprine (though make sure aza dose has been reduced initially to avoid bone marrow suppression from induction doses).

I hope that helps and sorry to ask so many additional questions.

Andy

Re: IMHA - weaning off meds...

Braden Collins — Thu, 25 Jul 2013 10:27:03 GMT

What is her body weight?

I normally try not to go below 2mg/kg daily until PCV and platelet count is normal. A recurrence of the Evans disease will kill her quicker than the Cushings. I look to gradually reduce the dose every 30 days or so by 0.5mg/kg, with weaning them off after around 6 months. If they relapse, I avoid weaning them off again. Concurrent use of azathioprin should help you wean faster if needed but don't rush it unless you have to.