IMHA 10 year old labrador

RE: IMHA 10 year old labrador

Thomas Johnson — Mon, 13 Jun 2016 16:15:14 GMT

[quote user="Mair Tyler"]

Thanks everyone for your help. I suspect this old boy isn't going to do although his PCV has remained stable since his transfusion. But he really is a very sick looking dog right now. It's rubbish -you know sometimes you just really want a case to go right, well that's how I feel with this one. It's hateful knowing you've worked so hard on something all weekend but know it'll more than likely be pts tomorrow...

[/quote]

In an older dog I'd be worried that there is a tumour somewhere triggering the IMHA, but I guess you need to wait until/if he improves before considering going on a hunt for one.

RE: IMHA 10 year old labrador

Martin Atkinson — Mon, 13 Jun 2016 15:54:03 GMT

[quote user="Andrew Kent"]I would be careful going over 2mg/kg per day of prednisolone in dogs [/quote]And never go over 40mg per dog whatever size of dog.

RE: IMHA 10 year old labrador

Mair Tyler — Sun, 12 Jun 2016 23:11:38 GMT

RE: IMHA 10 year old labrador

Busybee — Sun, 12 Jun 2016 21:55:16 GMT

Many thanks Andrew :) Glad to know I don't seem to be missing anything exciting!

RE: IMHA 10 year old labrador

Andrew Kent — Sun, 12 Jun 2016 21:37:09 GMT

[quote user="Busybee"]

[quote user="Andrew Kent"]i would also be careful about using 3 immunosuppressants together - I do sometimes but the risk of sepsis is much higher (up to something like 25%) so reserve for cases that have not responded to a double combo after 5 days or so or who have very aggressive disease.[/quote]

Andrew, is there any recent evidence to suggest that starting on a double combo (prednisolone + azathioprine particularly) has any benefit over prednisolone alone? As far as I was aware (and happy to be corrected!), azathioprine has a long lead in time of about 2 weeks (?) and studies in 2011 [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096914/] failed to show any advantage.
Would you use prednisolone + azathioprine in severe cases initially in order to just start it as early as possible in case the animal doesn't respond to prednisolone alone? Any views on mycophenolate?

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The evidence supporting any combination over another is lacking and the studies that do exist conflicting. The conclusion of the recent meta analysis is really that all the evidence is rubbish.

My rational for using a combination is often more to do with steroid sparing activity rather than improved efficacy and, initially, pred is likely the most important aspect. But many dogs have a lot of adverse effects on high dose pred so I would rather minimise the length of time I do that for.

In terms of choice of drugs - personally I hardly ever use azathioprine anymore. It takes too long to work (as you say) and has some significant adverse effects - others do use it frequently so this is completely personal opinion but it has been almost entirely replaced by mycophenolate for me.

I tend only to use azathioprine when cost prevents other drugs.

My 'standard' would be prednisolone and ciclosporin (and be aware that the doses required for ciclosporin may be much higher than the label dose).

Andy

RE: IMHA 10 year old labrador

Busybee — Sun, 12 Jun 2016 21:03:11 GMT

RE: IMHA 10 year old labrador

Andrew Kent — Sun, 12 Jun 2016 17:45:52 GMT

I would be careful going over 2mg/kg per day of prednisolone in dogs - there is no evidence that it is any more effective but has a significantly higher rate of adverse effects.

i would also be careful about using 3 immunosuppressants together - I do sometimes but the risk of sepsis is much higher (up to something like 25%) so reserve for cases that have not responded to a double combo after 5 days or so or who have very aggressive disease.

I agree with the comments that time is the key here and also the concern about underlying disease.

Andy

RE: IMHA 10 year old labrador

Emily Rainbow — Sun, 12 Jun 2016 15:50:26 GMT

Another here that starts at 2mg/kg BID of Prednisolone.

Omeprazole BID (off licence) to reduce gastric acidity. Continue maropitant and metaclopramide as necc.

Unusual not to be strongly regenerative at the start though in my experience as an IMHA alone. Bone marrow aspirate would be next step in the line of diagnostics if not strongly regenerative by now.

RE: IMHA 10 year old labrador

Glen McIntosh — Sun, 12 Jun 2016 14:17:24 GMT

Couple of other quick tips:

Dont forget to give anti platelet drugs if the animal is not also thrombocytopaenic as these cases are hypercoaguable and thromboembolic disease can be a serious complication (eg clopidigrel or low dose aspirin).

Pred is also a potent antipyretic so no need to give nsaid as well.

Ranitidine has been shown not to be a great gastroprotectant in dogs. Famotidine and omeprazole are more effective, and sucralfate is worth using, but wait an hour after giving other meds before administration.

RE: IMHA 10 year old labrador

Mair Tyler — Sun, 12 Jun 2016 14:09:25 GMT

No other relevant history that we can think of. Have started Zantac as gastroprotectant, also started amoxy-clav last night.

Opted for transfusion as PCV was steadily decreasing and he was becoming ataxic. Felt it was better to get some blood in at that stage than wait til he was recumbent!

RE: IMHA 10 year old labrador

Mair Tyler — Sun, 12 Jun 2016 14:05:32 GMT

No history of foreign travel or recent vaccination. Have started metoclop for V+/nausea. That's useful advice re fluids, would feel happier to start to get the bilirubin out of his system because that must be making him feel rubbish. OK will try to give him a bit more time. He's a lovely boy with lovely owners...so I guess he probably is doomed then!!

RE: IMHA 10 year old labrador

Richard Carter — Sun, 12 Jun 2016 14:03:10 GMT

no Hx of paracetamol, onions, garlic or other causes of haemolytic event- algae, Babesia, other drugs? Reason asking is the AIHA I've seen have arrived with obvious serious anaemia with v.v.strong regenerative response and usually WBC off scale. If toxic exposure and the RBCs have all been damaged then you will continue to see the PCV dropping as these are taken out of circulation.

Think you can go higher on the preds in the short term and combine with cyclosporin to get crisis under control.

Nausea is presumably due to the haemolysis so need to detox the liver if possible - vitamins, denamarin etc. May help to get some gastroprotectants in such as mucogel/ antepsin if you can get it, even kaolin will help absorb bile. I would also use a covering antibiotic with high dose preds going in.

I wouldn't be trying transfusions until PCV much lower - 12%

Prognosis guarded to poor - sorry to say - it depends if you can stop the haemolysis or slow it until the bone marrow can respond

RE: IMHA 10 year old labrador

Glen McIntosh — Sun, 12 Jun 2016 14:02:14 GMT

I usually put these guys on at least 2mg/kg pred, plus azothioprine +/- cyclospotine.

Yes, prognosis is very guarded for these guys, as many as 50% may die despite treatment.

But I usually advise owners that it may take at least 5 days before they stop getting worse (ie before they start responding to treatment).

Dont worry about giving fluids if the animal needs it, even if anaemic, PCV may drop but total RBC mass and number will not decrease because of dilution (but may do because of ongoing haemolysis). Total oxygen carrying capacity will not change. However, IMHA cases are usually not hypovolaemic, so don't need vast amounts of fluids.

Don't forget anti platet drugs like aspirin or clopidigrel as these guys are hypercoaguable and at risk of thromboembolic disease.

RE: IMHA 10 year old labrador

niall morton — Sun, 12 Jun 2016 14:00:44 GMT

I always start with pred and aza. Usually find pcv may still drop for a day or two but at a much slower rate. Takes another couple days of being stable before it starts to climb again. So I would give the poor guy a few more days.

Think the jaundice plus pred plus ketofen will induce vomiting in most animals. How about a metoclop infusion to help?

Went a Yvonne Mcgroty cpd a few years ago and think she said 10-20% mortality no matter what you do. Did his symptoms start after a vaccination?? That's usually what seems to be the start of the problems in cockers .

RE: IMHA 10 year old labrador

Robin Grimmer — Sun, 12 Jun 2016 13:53:29 GMT

Any history of foreign travel? In a dog of this age primary aiha would be less likely. I would be much more suspicious of an underlying cause for the aiha eg neoplasia so prognosis would be much more guarded.