Aplastic Anemia

Welcome to the forum. I don't have any experience with this but hopefully others will be along who have. There are a lot of caring and experienced folks here. I wish you the best of luck with treating this.

Quick question .... have they ruled out AIHA/IMHA?

WE have a GIGANTIC thread on here for IMHA/AIHA -- are they thinking this IS auto-immune?? (hence the cyclosporine?)

Aplastic anemia simply means it's anemia that is happening in the bone marrow -  i.e., the body either isn't manufacturing blood or the blood isnt' making it OUT of the bone marrow.  You can have aplastic anemia that isn't immune-mediated (and it can have been caused by toxins) but the treatment likely wouldn't include cyclo unless they were pretty sure it WAS IMHA.  (immune-mediated hemolytic anemia -- the body is killing it's own blood -- and "aplastic" would mean destruction in the bone marrow). 

Are they seeing destroyed red blood cells in the marrow, or is there excessive lipids in the bone marrow that make the body not MAKE blood. 

There are darned few message boards out therre where folks even know the difference between all these but there happens to be several folks on here (outdoorschik and I both being among that group) who have had dogs with IMHA. 

I'm at work and I"m leaving for the dentist in 2 minutes so if someone could kindly give this lady the URL for the AIHA or IMHA  267 page thread on there that would be great. 

I'm going to PM you my phone number -- I would be glad to talk to you later (like after 5 e.s.t.) if you want -- I'm no expert on the non-immune-mediated Aplastic Anemia but I know tons about IMHA and Aplastic Anemia that is caused by destruction (rather than just none being produced). 

Welshies, unfortunately, are hard-wired for blood diseases.  But we'll certainly help you if we can -- and among those "words" I will tell you that I have a dog (Billy) who is a 4+ year survivor of IMHA -- he had SIX transfusions in the first month of the disease and YES he survived, thrived and got OFF all the drugs.  *hugs* -- I do understand only too well. 

I have no experience with this condition but I'm sending you and your dog good thoughts and vibes.  (((hugs)))

I'm sure Callie must have been thinking of some other breed when she said that Welsh Terriers are hard wired for blood diseases.  The breed has few genetic problems and blood disorders are not among those few. 

Here is the link for the "AIHA or IMHA" thread:  http://forum.dog.com/forums/p/90432/921061.aspx

JackieG

I'm sure Callie must have been thinking of some other breed when she said that Welsh Terriers are hard wired for blood diseases.  The breed has few genetic problems and blood disorders are not among those few. 

You're right Jackie -- I was thinking another terrier breed.  That's what I get for trying to post on my way out to the dentist.  Thanks for catching that.  And Thanks Janet for posting that link.

My baby girl's name is Josey...just wanted to mention that so I can use her name.  So she has been diagnosed with an immune mediated aplastic anemia.  She is not making any red blood cells at all in her bone marrow.   She has been tested inside and out for causes and there are none.  All of her other blood labwork, ie: her platelets, wbcs, are normal.  That poriton of her bone marrow is functioning just fine.  The last pcv I know of was 24 and that was this past Tuesday.  She was transfused on Saturday, Feb 5th, and they tell me the blood will be good for about three weeks....then what? 

 In regards to the milk thistle, how much do you give a 22 pound dog?  I know I can get it in capsule form...do I just break it open then and add it to her food?

 I am still waiting to hear from the vet today about starting her meds.  They were waiting on a cortisol level to be sure it wasn't Addison's disease.  If that comes back normal, we will start the medication, prednisone and cyclosporine.  If it is abnormal (low), then they want to run one more test to confirm Addison's.  I am really getting anxious about getting her started on something.  It seems like it is taking an eternity and I am very scared. 

 This forum will be so helpful and I need all of the encouragement possible right now as I feel very discouraged. 

So it is AA and not IMHA -- wow... have they done a bone-marrow aspirate?  In other words how have they determined she's not 'making' any?  I'm not being snarky -- but it's tough sometimes to make sure we're all on the same page.

Glad they are being careful.

I know you are a nurse from your email -- but in total honestly there are times when alternative medicine can be extremely helpful -- there's something calle homotoxicology that can make huge changes in a body balance problem like this -- if I was faced wtih either Cushings or Addisons it would be MY choice of how to treat.

Start her on whatever she will tolerate for milk thistle -- if you can give her 1/4 tsp (which is about the contents of one capsule) twice a day in her food -- the loose powder is better because they don't have to deal with the cellulose in the capsule.  Then increase from there to whatever she will tolerate.  You can get milk thistle in a loose powder in bulk form -- you just want a GOOD brand -- organic is better, wildcrafted is best (but those can be hard to find).

Your vet may have Marin as well -- that is the pharmaceutical version (the herb actually is more beneficial for many reasons but use whatever you can).

This probably won't post so I'll keep it short!

Any news?  You could always treat with cyclosporine and/or dexamethasone prior to testing for addisons and it won't affect the results!  I can't see it being addisons but who knows with NRAIHA / PRCA.

Did they do a bone marrow biopsy/aspirate?

I heard from her briefly this morning -- and MAYBE this will pst for me.

 She's taking her to U of Wisconsin!!! RAH!!!!  That's where the Rabies Challenge Study is being done (Dr. Schultz and Dr. Dodds) -- that's an awesome place for her to take her. 

This has been an overly frustrating week and I am doing my best to be encouraged. 

To clarify Josey's diagnosis according to her discharge papers....she has a non-regenerative anemia....she did have a bone marrow aspirate that showed that she does not have any red cell precursors (immature red cells) in her bone marrow...therefore she has a pure red cell aplasia (PRCA) which they feel is due to an autoimmune etiology.

We have been doctoring at UW now since Friday, February 4th when my vet rushed us over there.  She was transfused the following day, February 5th, and we have been seeing a vet in internal medicine since the 8th.  She has had a battery of tests done: abdominal ultrasound, multiple bloodwork, ecg, blood pressure, etc.  The bone marrow aspirate obviously was the most telling.  She has been worked up as an atypical Addisonian dog and I did not pursue this further since the treatment for the Addison's disease also consists of prednisone.  We will be rechecking her electrolytes as well as her PCV to help with the addison's disease issue.  Her next check is February 22nd, and I am hoping that her tranfusion will hold out that long.  The vet told me, generally, a transfusion is good for three weeks.  Does anyone know if this sounds accurate?

We finally got her medications today.  They have started her on Prednisone 20 mg once a day and Cyclosporine 50 mg twice a day.  I asked for the Atopica brand and did not receive it.  I am disappointed about this but the pharmacist I spoke with assured me that the modified cyclosporine they sent me home with is one that they use all of the time on animals.  Unfortunately, they sent me home with 50 mg capusles and they are as big as her tongue.  She is 22 pounds and one bite into that capsule and she will spit it right out. 

 I am having a very difficult time today getting her to eat.  She is finnicky to begin with and I am afraid she is starting to feel yucky again.  Any suggestions on what to try to feed her?  I have liver, ground turkey, ground beef, baby food, cheese, lunchmeat, hot dogs, kibble, scrambled eggs...I know this is of utmost importance.  She was able to get some milk thistle in her this morning but then when I came home, I found some vomit with it in it.  She also is wanting to eat a lot of dirt from the houseplants in my home.  I have covered them all now, but does anyone know why this is? 

Thank you to all that have responded.  I just want to turn this around for her and get her back to her usual health.

If it's the *modified* version it will be fine.  That word "modified" tells the whole tale.  They can, I think, do a liquid of the modified version that might be easier eventually.

Getting them stable is very difficult -- try anything for food.  don't present her with much -- just tiny bits (the smell of food can sometimes be entirement and sometimes off-putting) --

Try adding a bit of water to babyfood meat and put it in a baby medicine syringe and try just syringing it in her mouth.  Sometimes if you can get it past the mouth to the gut it will then make them feel a bit better and they'll then eat.

baiceyjo7

The vet told me, generally, a transfusion is good for three weeks.  Does anyone know if this sounds accurate?

Good to hear you finally got meds to start.  Ask the doctors about pulse dosing the cyclosporine.  By this I mean use for weekdays then take Saturday and sunday off.  This has proven to work remarkably well for dogs with bone marrow issues related to this disease. 

You'd be very wise to pick up some sort of hematinic consisting of B vitamins, folic acid and iron supplements.  Many of us here use a product called pet tinic.  A hematinic is provides all the needed micronutrients for proper hematopoiesis (blood building).

I'm also curious as to what they found with regards to thyroid testing.  Most idiopathic cases of NRAIHA / PRCA have an underlying hypothyroid issue and sometimes can be directly related to autoimmune thyroiditis which will only show with FULL thyroid testing.  Dr. Dodds recommends supplementing these particular cases REGARDLESS thyroid results with low dose soloxine or equivalent starting at a dose of 0.1mg for every 10 pounds of weight.  This also aids in stimulating the bone marrow.  If after a week of doing all this there is still no response then you can consider other options like anabolic steroid injections.

I'd be wanting to check reticulocyte levels fairly regularly...like at each visit along with full CBC's.

The food you listed above sounds good but I'm wondering if you're using a stomach protectant?  Pepcid or sucralfate or prilosec are among the commonly used protectors and you NEED to use one or several of these everyday!!!  You could also consider using an antinausea drug like cerenia or metroclopromide/reglan to help with appetitie OR even better use the slippery elm cocktail which works really well.

If these fail then you could ask the vet to give an rx of mirtazapine.  This is a human antidepressant that works really well to stimulate the appetite...reall really well!

Do you have copies of all the bloodwork done thus far?

 I'm so sorry you're going through this with Josey, but you're in REALLY good hands with Johnny and Callie and everyone else! My dog Jasper was diagnosed with immune mediated pure red cell aplasia (just the red cell series in her bone marrow was affected, like Josey if I remember correctly...) a little over three months ago, and I so feel your pain! A few things I've learned:

--even though IMHA and PRCA are essentially the same (immune-mediated destruction of red blood cells), the location of the destruction (in the veins versus the bone marrow) makes the two super different! I think the initial crash with IMHA is a lot more severe, and the crazy bodily upheaval can cause a lot of systemic problems that complicate the effects of the anemia. The onset of PRCA is slower, and then it's just a whole lot of waiting waiting waiting for the immune system to right itself and let the red cell series build back up again.

--Like Johnny said, reticulocyte counts are a huge deal! It means that the destruction is under control enough and the immature red blood cells are able to make it out of the bone marrow and into her veins without getting snatched up and destroyed.

--With Jasper, and I think PRCA in general, her transfusions did last for about 2 or 3 weeks. Since IMHA-destruction is focused on the RBCs circulating in the veins, putting more blood in circulation, especially when it's not the dog's blood to begin with, can send everything into overdrive and increase the rate of destruction. With PRCA, since the destruction is tucked away in the bone marrow, the transfused blood can kind of sneak in and is able to hold things steady for awhile. Since it can take awhile for the bone marrow to be able to regenerate again, she might need a few transfusions to keep her going until she's making her own, so it's really lucky that we get some mileage out of them!

--It sounds like they're starting off pretty strong in terms of treatment which is so awesome! Immune-mediated lysis can switch targets really quickly, and she's got enough work ahead of her with building her red cell series back up, so getting the destruction under control before it moves onto some other blood component is a big deal. 

 --Jasper had a really hard time with the herbal milk thistle, but the Denamarin was actually a lifesaver--it's a more bioavailable formula, so she could take a big enough dose to protect her liver and she didn't have any of the gastrointestinal problems that she'd had on the herbal. Keeping Josey eating is the biggest thing, because it's the only way she'll tolerate the drugs, which in turn is the only way she'll beat this, so don't be afraid of the Denamarin if the herbal is a little rough on her!

--BE NEUROTIC! Not to the point where you're driving yourself insane, but IMHA/PRCA is all about staying ahead of the curve. The drugs are really hard on their systems, and the immune-suppression makes every little bug a huge danger, but it helped me to expect the worst and jump on every tiny little weirdness that she came out with, because we ended up catching a lot of issues before they became overwhelming. Check her temp, monitor her stool, and urine dipsticks are really helpful too--a legitimate urine analysis is a good idea to do regularly, but the dipstick can help you get a jump on anything that might be brewing.

--It might be a good idea to check her PCV pretty frequently early on, at least until you have an idea of where she stands and fall into a rhythm. I had Jasper's checked twice, sometimes three times a week when she needed frequent transfusions, and since she started regenerating we've been checking her cbc/chemistry weekly to make sure her red cells are ok, her white cells aren't showing infection, and her organs are holding up against the drugs. 

--Ask a ton of questions, do a ton of research, save allll of her bloodwork, and stay positive!! Even when everything is falling apart, don't think about what's going to happen, just focus on putting her back together, loving her, and getting her through it : ) Jasper's 10 years old with an inherited bleeding disorder, and she wows me every day with everything she's managed to work through. Seriously though, I know how overwhelming this is, and throwing myself into researching PRCA helped me keep everything straight, stay ahead of her symptoms, and gave me an outlet for all of the emotional craziness of having a really sick, beloved pet and made me feel less helpless. It's a pretty demanding situation, and having that knowledge can help you be a more effective....middleman, I guess, between Josey and her vet, and your knowledge of Josey and what she's dealing with can help your vet make the best decisions regarding her care. But again, just channel all of that fear and helplessness and frustration into power and ferocity, and get ready to kick some PRCA butt! : )