IMHA IMTP

RE: IMHA IMTP

Beats — Wed, 04 Jan 2017 00:56:32 GMT

Probably not suitable strength for a cocker, but 250mg capsules of mycophenolate mofetil (Myfenax; TEVA) are very reasonably priced.

http://www.tevauk.com/p/mycophenolate--232

RE: IMHA IMTP

Andrew Kent — Tue, 03 Jan 2017 16:04:13 GMT

[quote user="chris Jones"]

that's interesting about the giant platelets.

when his count was 'normal(ish)' in august time he still had giant platelets and some clumping.

[/quote]

Do you have any bloodwork from before this dog was unwell? Do we know it used to have a 'normal' platelet count?

There is a genetic test if you consider macrothrombocytopenia possible: http://www.laboklin.co.uk/laboklin/showGeneticTest.jsp?testID=8217

Andy

RE: IMHA IMTP

Andrew Kent — Tue, 03 Jan 2017 16:01:27 GMT

[quote user="Stefano Zago"]

Hi Chris

In addition to what Andrew has written, I've used melatonin in several cases of IMHA and IMTP with good results to the point of managing some dogs just on melatonin. There is no data in dogs but quite a bit in humans. It seems to be very well tolerated, with no side effects except some sedation and at a reasonable cost. Vetruus makes Melacutin (3mg tablet) and I would use 3mg bid for at least 1 month before deciding it's not working.

Stefano

[/quote]

I think the melatonin thing is interesting but I'm not completely convinced. Most dogs who are treated with it also have conventional treatment so assessing the response is almost impossible. I have tried it in a few tricky cases and had some success and some disappointment so who knows.

Even the evidence in humans is old and not entirely convincing.

But I agree worth a go in difficult cases.

Andy

RE: IMHA IMTP

Stefano Zago — Tue, 03 Jan 2017 15:27:06 GMT

Hi Chris

Stefano

RE: IMHA IMTP

chris Jones — Tue, 03 Jan 2017 14:24:00 GMT

thanks

that's interesting about the giant platelets.

when his count was 'normal(ish)' in august time he still had giant platelets and some clumping.

I will have to look at the costs and talk this through with the owner

chris

RE: IMHA IMTP

Andrew Kent — Tue, 03 Jan 2017 14:15:54 GMT

[quote user="chris Jones"]If I started cyclo/myco how long would you suggest to keep on this before rechecking the bloods and attempting a reduction in preds? 4 weeks?[/quote]

Mycophenolate takes up to about 2 weeks to reach full activity (like azathioprine) so I would give it at least that long before reducing steroid dose.

Ciclosporin can be variable, it may work more quickly but I would still leave it at least 2 weeks ideally.

Mycophenolate is cheaper than ciclosporin in some formulations but, as the tablets are not divisible, dosing can be tricky. If less than about 20kg then there is an oral solution but its a little more expensive.

Andy

RE: IMHA IMTP

Andrew Kent — Tue, 03 Jan 2017 14:12:46 GMT

Thanks Chris - so it does look like a true fall with evidence of platelet regeneration in the giant platelets. The presence of macroplatelets can confuse things a little as the count can be low with a normal total platelet volume (plateletocrit).

When the count is normal do the giant platelets disappear (the only reason I ask is that Cockers can rarely have giant platelets and consequently lower platelet count as a 'normal' finding like the Cavaliers do).

But based on the above considering another immunosuppressive drug sounds sensible.

Andy

RE: IMHA IMTP

chris Jones — Tue, 03 Jan 2017 14:08:48 GMT

sorry had to post again as the computer was typing backwards !!

he seems fine at the moment.

The last time I tried to drop the dose in octpber the platelet count on the machine was the same at 8 but the smear count suggested a reduction at this stage.

he did knock his mouth last week and has a small bruise on the gum line from it which makes me a little nervous about attempting a reduction in preds yet.

If I started cyclo/myco how long would you suggest to keep on this before rechecking the bloods and attempting a reduction in preds? 4 weeks?

chris

I will have a look at the costs of myco and cyclosp.

RE: IMHA IMTP

chris Jones — Tue, 03 Jan 2017 14:01:30 GMT

Hi Andrew,

thanks for the reply. At the time of the original diagnosis we did do chest and abdo rads and full bloods but couldn't find anything obvious, probably need to recheck this area.

the platelet count has been done on our machine but was reading low but since then I have been sending it to an external lab for smear evaluation, the count does stay low and drop further with a reduction in dose. the most recent result is as follows.

~~~~~~~~~~~~~~~~~~~

HAEMATOLOGY RBC 6.49 x10^12/L (5.0 -8.5 ) Hb 15.9 g/dl (12.0 -18.0 ) HCT 48.4 % (37.0 -55.0 ) MCV 74.6 fl (60.0 -80.0 ) MCH 24.5 pg (19.0 -26.0 ) MCHC 32.9 g/dl (30.8 -37.0 ) RDW 14.2 % (12.9 -17.8 ) Platelets * 8-See haematologist's comment WBC * 18.51 x10^9/L High (6.0 -15.0 ) Neutrophils 10.55 x10^9/L (3.0 -11.5 ) Bands * 3.33 x10^9/L High (0 -0.3 ) Lymphocytes 3.33 x10^9/L (1.0 -4.8 ) Monocytes 1.30 x10^9/L (0 -1.3 ) Eosinophils 0.00 x10^9/L (0 -1.25 ) Reticulocyte % 1.2 % Reticulocyte count 77.88 x10^9/L Platelet comment Giant platelets and platelet clumps, Actual platelet count appears normal RBC comment Slight polychromasia Slight anisocytosis Leukocyte comment Dohle bodies present

CLINICAL COMMENTS

As previously, occasional very small platelet clumps are present at the feathered edge and within th body of the smear; this makes definitive assessment and comparison to previous results difficult. However there are on average 2-4 platelets / x 1000 field, equivalent to an estimate of 40-60 x 10^9 PLT/ L as a minimum value, suggesting that there is still a subjectively moderate thrombocytopenia. Macroplatelets are present as beforer

~~~~~~~~~~~~~~~~~~

RE: IMHA IMTP

Andrew Kent — Tue, 03 Jan 2017 13:17:21 GMT

Hi Chris,

What kind of falls are you seeing? To below the reference range? Supported by a smear evaluation?

The reason I ask is that it is normal to see some fluctuation in platelets as the pred is withdrawn plus with clumping the true count can be challenging to determine so sometimes we just have to hold our nerve!

The other question is did you look for underlying causes at diagnosis? Whilst the signalment is pretty typical dogs with underlying disease can often be less responsive to treatment so, if not done, thoracic and abdominal imaging could be useful.

In answer to your main question - there is a lot of personal experience in which drugs to use and everybody will often tell you different things but the main options are:

1. Ciclosporin - starting at 5mg/kg PO every 12 hours

2. Mycophenolate - starting at 10mg/kg PO every 12 hours

3. Azathioprine - starting at 2mg/kg PO every 24 hours dropping to every 48 hours after 2-3 weeks.

Azathioprine is by far the cheapest option and is very safe with appropriate monitoring but does have some serious potential adverse effects. I use a lot of ciclosporin but can be cost prohibitive in some cases.

Andy