AIHA or IMHA

Coopbay

Right after I sent the post, my regular vet called. She just talked to the Arboretum Vet and he told her that he doesn't want to lower the dosage of the Pred until Cooper is in the normal range and then he wants to slowly go down by 5 mg each time. Cooper takes 20mg in the morning and 20mg at night so he would have me go to 20 in the morning and 15 at night. He would decrease the Pred over 8-10 months. He also said that Cooper doesn't need to go get his PCV checked every week and instead to go in 3 weeks and have a liver screen and a full CBC.

That is exactly how Willow was weaned off her Prednisone.  It took her five months to come off of it. 

Bath mats are a good idea. We started using a bunch of old towels and beach towels to put in the kitchen since they cover a large area. I think it's funny what you said about Pirate freaking out with the puppy pads because Cooper and Bailey think a puppy pad is a giant kleenex. They try to tear it up and play with it.

We'll be using towels as our pee pads for the next few months now. :)

 Lori- it's good to know that my vet is doing what other's have done with the being on the pred for so long. I'm hoping it won't do too much damage to his body.

Johnny&Tessy

Her belly seems to be getting a little larger than normal so I guess that'll be my new worry.

They get quite the belly with pred and the steroids -- particularly wit the prednisone.  It's NOT fat ... it is water retention from the pred and it's a normal side effect that will **ultimately** go away (months after they are off the drugs -- and Billy's took a LONG time to go away -- not just after the pred but after he was off ALL the steroid-like drugs).

Coopbay

Right after I sent the post, my regular vet called. She just talked to the Arboretum Vet and he told her that he doesn't want to lower the dosage of the Pred until Cooper is in the normal range and then he wants to slowly go down by 5 mg each time. Cooper takes 20mg in the morning and 20mg at night so he would have me go to 20 in the morning and 15 at night. He would decrease the Pred over 8-10 months. He also said that Cooper doesn't need to go get his PCV checked every week and instead to go in 3 weeks and have a liver screen and a full CBC.

Even my *holistic* vet told us very very seriously NOT to rush getting off the drugs.  I was pretty suprised given how slowly his packed cell volume is coming up that they were even talking about reduction.  If his body truly weren't attacking itself the PCV would go up faster, so there's still need for caution there. 

The ideal wean-off is very very slow ... and sometimes if the dog's body begins to show signs of weakness regarding a drug they have to do it quicker, but generally the whole deal with the wean-off is to do it literally so the body doesn't "notice" the reduction.  Particularly a drug like pred that is absorbed faster than the azathiaprene and the cyclosporine.

I guess I'm not overly concerned with the stomach because there is barely any size to it at all.  I think I'm just more concerned with her next doctor visit this week.  I can tell by the look of her gums that her HCT is staying approximately the same in the high 20's so I think we are going to adjust the meds by lowering the azathioprine from 37mg to 25mg.   Tessy's HCT seems to hover around the same mark for quite some time now.

Just a general question for everyone.....Do you think that the Azathioprine would be the best drug to lower as apposed to the prednisone or cyclosporine.  I'm fearing that one of these drugs are suppressing her marrow too much.  Her blood sizes are starting to go to normal levels also so I'm not sure if that might mean something.

Thanks everyone...I hope you are all having great weekends.  Hugs from Tessy & I.

Johnny & Tessy

All 3 drugs suppress the immune system.  Not sure what you mean by supression of the bone marrow.  A large degree of IMHA is *where* the body is killing the blood.  For example, with Billy all his reticulocytes (baby red blood cells) were disappearing in the bone marrow immediately after they were 'born' and not making it TO the blood.  Gratefuldawg's girl, Cloppie, was losing hers IN the blood and only adult cells.  The body wasn't targeting reticulocytes at all.

20 is generally not considered high enough.  I would think they would try to determine if the body is still waging war on the blood -- or exactly what's going on.  "normal" is the high 30's to high 40's/low 50's.  PCV/hematacrit that is still in the 20's could be indicative of several things:

1.  that the body is still killing some red blood cells (that the body is roughly killing almost as many as being born allowing for some natural "loss" of aged red blood cells

2.  how much red blood IS the body making?  is it enough?

They'll look closely at the blood to see if they see any destroyed reticulocytes or red blood cells and WHERE they find them.  I kinda doubt that they will reduce much if they are still seeing destroyed red blood cells in the blood.  That's going to tell you that the immune system is still actively ravaging the blood.

 In other words they are going to try to figure out why the PVC isn't rising above the 20's.  Each drug has it's own downside.  Azathiaprene tends to be hard on the liver -- but then, the liver is the only organ in the body that regenerates.  Cyclosporine is not only expensive, it is *very* hard on the kidneys.  My caution there would be that kidney damage is DAMAGE.  Meaning, un-recoverable.  But it also tends to be the drug of choice for IMHA.  Pred -- pred has a lot of side-effects.  Kidney, liver and it even tends to cause things like diabetes, Cushings, Addisons, etc.  (well all 3 of those drugs do). 

But pred is also the easiest drug to taper off.  I don't know which they'll target first.  They may go by blood results. 

If you are not already, pleae please be using milk thistle in vast quantitites -- it helps protect both the liver AND the kidneys (you have to use a huge dose to protect the kidneys, but as to what I said above, damage to the kidneys is permanent, therefore definitely worth the effort to protect the body).

They tend to want to wean off very very slowly -- and frankly that can be tough with cyclosporine because it only comes in the specific caps if you are using Atopica.  10, 25, 60, 100 - that's all you get.  So often they get really creative in order to lower the dose -- for example you don't go from 100 to 50.  You go from 100 to 95 (a 50, a 25 + 2 10's) or 85 (a 50, a 25 + a 10).  The point is to literally fool the immune system into not "missing" the elminated amount.

 It eventually becomes quite a race -- to get the dog weaned off the drugs before the drugs too severely compromise the dog's health. 

Knowing what Billy's reactions were, I probably would have preferred azathiaprene, altho it's generally the lesser preferred drug, but the milk thistle can SO help protect the liver.

Are you doing anything to build the blood?  High iron foods?  acupuncture? 

One thing that both Gratefuldawg and I BOTH learned the hard way ... **ASK** for them to test the iron levels in the dog.  That can also be a huge  clue as to how hard the body is working to build blood.  both Billy and Gratefuldawg had to be iron supplemented (which has it's own side effects).  But there are SO many iron-rich foods that can really help TONS.  I home cook for Billy and he ate everything from beef heart (GOBS of it) to liver, of course, to turnip greens & kale and other leafy greens (including romaine lettuce, beet greens & root, etc) and hummus (chick peas), plus prunes and other "sticky" fruits (figs, dates, etc -- they're all high in iron).

It is not typical for them to test for iron -- and a lot of vets don't seem to know to do it unless you suggest it.  But if the body's not replenishing its blood reserves it can be simply because the blood is iron-poor.

I'm not OVERLY sure where the red blood cells are being destroyed. I can only assume that it is in the blood (not sure what you mean about adult cells). I'm still learning about this disease (new stuff everyday it seems). I say the blood because she is regenerating and the tests show reticulocytes and mixed RBC sizes.  As far as the retics go...I can only get these numbers if I send the blood away.  My finances are a little tight so I do not have the option of sending them out often.  I usually look at the signs like the RBC histograph, the MCV and the RDW numbers to help determine the presence of retics.  The concern now is that her RBC sizes are falling to within normal ranges...I do not know if this means the retic production is slowing or what.  I've read many cases where a dogs HCT was staying stable in the high 20's (or somewhere near this) and the drugs were reduced.  After the reductions the HCT slowly started to climb.  I know this is probably different with each case but I feel we hit a road block of sorts.  Tessy has yet to get over a 30 HCT.  Her last test showed a 27.7 hct which is where it's been for 3-4 weeks now.  Dr. Dodds was the one who said to reduce the azathioprine if we did not see an increase at the next appointment.  Although her cyclosporine trough test showed a number of 200+...I still wonder if 200mg/day is too much for a 36 pound dog.

"They'll look closely at the blood to see if they see any destroyed reticulocytes or red blood cells and WHERE they find them"  What do you mean "WHERE?"  I was thinking that maybe I should send the blood off this week again to get tested.  OR maybe they could look at a smear to see if there are spherocytes present or retics.  I'm just not sure what to do.  The last time her blood was sent out was on April 8th.  Those tests showed an RBC morphology of...Spherocytes 1+ (down from 2+), Macrocytosis 2+ (same), HJ Bodies 2+ (down from 3+), Anisocytosis 4+ (up1), Polychromasia 4+ (up2).  Her last Retic # was 13% (403 x10E9/L).

Her CBC pathology report quoted " moderate leukocytosis - moderate neutrofilia, moderate left shift = inflamation.  Moderate anemia - regenerative, some spherocytosis.  mild thrombocytosis - reactive?"

Tessy's HCT climbs really well until it gets to the high 20's.  The first month of her treatment it climbed as high as 29 and stayed there for a few weeks till she had a relapse.  (her HCT fell back down to 20...so I don't know for sure if this is considered a relapse or not)

She does not take Milk Thistle.  I think I'm going to put her on it really soon.  Her diet may be of concern a little.  She eats chicken and green beens as a large part of her diet.  She also gets white potatoe, liver, roast beef, fish sometimes, few teaspoons of pumpkin  and a teaspoon of icecream 3 times a day to put her meds in.  I give her a multi-vitamin with her dinner everyday also.

Anyway, sorry for the length here.  I figure I might as well put some detail here in case anyone wanted to know.  Myself...I love hearing the details from others.

Thanks again everyone for the advise and help.  It is much appreciated.

Johnny & Tessy

This is gonna be a long one.  But certain things need to be re-stated at this point and I want to answer Johnny's questions as best *I* can.  I'm not a vet, but I love a dog who is an IMHA survivor. 

Johnny&Tessy

I'm not OVERLY sure where the red blood cells are being destroyed. I can only assume that it is in the blood (not sure what you mean about adult cells). I'm still learning about this disease (new stuff everyday it seems). I say the blood because she is regenerating and the tests show reticulocytes and mixed RBC sizes.

Much depends on who has been overseeing the dog's care -- and usually at a university their "job #1" is to find out WHERE the blood is being destroyed.  i.e., in the bloodstream or in the bone marrow.  They do that by monitoring whether they *ever* see reticulocytes (baby red blood cells) in the blood or do they only see adults.  Sounds like they're seeing baby red blood cells IN the blood from what you're saying. 

Do you know what her average 'crit was before the disease?

(for those just joining us let me explain a bit:  red blood cells aren't all identical.  There are different sized ones which often equates to how old they are.  Red blood cells are "born" in the bone marrow (and when they are babies is when they are termed "reticulocytes";) and then come out into the blood stream later. 

a "hemoatocrit is a machine done test on the blood to see how many red blood cells there are per unit.  Literally it's all done BY machine.

a PCV or "packed cell volume" is done by hand.  They take a sample of the blood and it's put in a cetrifuge in a wee tiny tube and the blood will 'separate' into its components and they then measure the red portion of the blood against a chart and arrive at a "packed cell volume".  IT IS THE SAME THING AS A HEMATACRIT -- except a PCV is done by human hand. 

More chance of error?  yes

HOWEVER -- a hematacrit will change depending on the machine used so there is always a "margin of error" for both. 

from there the blood is also categorized into the various different types Johnny mentioned. 

As far as the reduction in meds - it is all a great big huge puzzle, and yeah all sorts of things are "norm".  Mostly because this is just NOT a disease where classic medicine really performs well.  You just can't do a 'study' and say "well, 65% of those studied do well on X mg of ABC drug given bid."

Why?  Because the other 35% may be dead ... or any one or 'few' of that 65% may walk across the room and throw an embolism and die before they walk out of the vet's office. 

In this particular disease vets have to watch each individual animal SO carefully -- they look at the liver and kidney numbers in the blood work and try to guess which drug is likely to damage THIS dog the least and when is it safe to reduce a drug.  And you GOTTA reduce them sometime because prolonged use of any of these drugs carries huge huge mega side effects -- many of which are life-threatening.

Ok -- so that being said ... what next? 

First off, if you have Jean Dodds working on your dog, you have upped your odds right there.  The lady KNOWS her stuff and blood is her life's work.  And she's jumped into IMHA and the other auto-immune blood-related diseases (including cytopenia of all it's various forms) and has done incredibly helpful stuff. http://www.hemopet.com if anyone wants to look at her website.

Johnny&Tessy

I still wonder if 200mg/day is too much for a 36 pound dog.

It's a lot, particularly given that the dog is also on azathiaprene AND pred. 

Johnny&Tessy

Tessy's HCT climbs really well until it gets to the high 20's.  The first month of her treatment it climbed as high as 29 and stayed there for a few weeks till she had a relapse.  (her HCT fell back down to 20...so I don't know for sure if this is considered a relapse or not)

Yeah, non-professionally speaking I'd say it was a mild relapse, but count your blessings because with THIS disease most animals that relapse, do it hard, fast and usually fatally.  But often that relapse occurs after people have stopped the daily worry and have stopped getting the 'crit read at all frequently. 

My husband and I developed our own set of "criteria" for how to read how Billy felt.  for ME it was 999 "normal" behaviors and whether or not he continued them.  For my husband (and later for me as well) it was simple.  How hard is he wagging/aka "vibrating" that non-existent nubbin of a tail of his?  THAT usually told the whole store in one easy to see "Hmm, he's not happy -- you feeling ok, buddy?"  And we'd go racing to the e-vet or all the way up to Gainesville.

However -- that leads me to another discussion.

Relapse.  Go back to a calendar and look HARD at it.  What happened that day or a few days before?  Had the dog been outside in public?  To a dogpark or exposed to other dogs? (anything that could have caused the body to have to 'respond' to any sort of immune challenge). 

How about emotional challenges?  Some unexpected schedule change?  any family upset?  (someone got mad or upset, someone went away on vacation or back to school or ANY CHANGE in the emotional tenor of your home at all??  were YOU stressed at work?)

No, I'm not crazy -- my holistic vet was telling me the other day about a dog who came in with IMHA and the "change" was that it was a home of a single mom (dog was a shih tzu) and BOTH daughters went away to college at the same time.  The one had taken a year off to earn money and they both went to college at the same time so they could room together.  The dog literally was shattered at losing both girls at the same time.  The dog began to RECOVER when the girls came home for a couple of weekends and gave the dog some attention!!

Next and probably most importantly -- toxins.  Make a list.  Check the calendar.  Wreck your brain but think back to that week and just prior and think of what "chemicals" or unusual scents the dog may have come into contact with.

This could be as simple as a dose of heartworm preventive or Frontline.  (no, it does NOT matter that the dog may have had ti umpteen times before -- they CAN become suddenly sensitive).  It can be far more difficult to pin down -- things like:

was the dog recently groomed or boarded?  (you have to consider pesticides used THERE as well)

Any sort of chemical pesticide -- like Frontline, Advantage, Advantix, ProMeris, ProHeart 6, 12 or whatever, Revolution, BioSpot, Interceptor, Sentinel, HeartGuard, anything with ivermectin, milbemycin or any known paraciticide.

Any sort of vaccine of ANY kind (bordatella, rabies, combo, individual)

Any sort of antibiotics or surgery.  (there are some antibiotics that are far more apt to 'trigger' auto-immune diseases than others.  AND these dogs who are already receiving treatment may also be breaking out with inflammation or diseases ***because*** they are taking immune suppressors -- my notes in the last thirty ... what, we're up to 36 now?? pages -- tells a lot about how nasty and awful Billy's skin was during the entire course of taking the steroids and steroild-like drugs.  He was a sitting duck for infection of ANY sort and his middle-name was inflamed.  You can't LET them be inflamed because inflammation of any sort **can and will** trigger a relapse.  But you're darned if you do and darned if you don't because a major antibiotic change can ALSO trigger auto-immune.  So you treat carefully and with nerves of steel every time.  You use herbs where you possibly can (and even regular vets are learning the wisdom of this). 

your yard being fertilized or pesticide being put out

you **neighbors** yard being fertilized or pesticide put out

your city/town, etc. being sprayed by air

did you change what you cleaned the floor with? new air freshener?  new bathroom cleaner?  new furniture? 

Ok why the third degree?  Because -- if you can nail down the cause or the "trigger" that started the disease (or the relapse) you can then have a FAR better chance of avoiding the problem in the future and of them getting off the drugs fully and being able to have a normal life.

True example (near as we can reconstruct) -- Billy got bitten by a tick.  Yes, a darned tick.  I found it on a Sunday morning ... it was embedded but didn't look like it had started to "swell".  But it WAS embedded which means that's when tick disease is communicated.  so I was watching for "tick disease".  (In Florida ehrlichiosis and babesiosis are the two baddies here and I bet I screwed up the spelling on both of those). 

BECAUSE I was watching for tick disease, I didn't hesitate to take him to the vet 6 weeks later when he was acting just a wee tiny bit "off".  He wasn't jumping up on the water bed like normal -- almost like he was a bit "nauseated".  We caught it EARLY.  His pcv was 20.  The vet was astonished because he was completely 'asymptomatic' (showing no symptoms).  We had done a blood panel JUST BECAUSE I suggested it.  It was 3 years ago the 3rd week of May.  . 

The vet started him on prednisone (that was Saturday) and we did another blood test about 10 days later and his PCV was 29.  Great.  But the vet decided to do a tick test with that because we didn't want IMHA and it COULD be tick disease and still be responding just to the prednisone... tick disease would be easier to treat and less dangerous.  So it was sent it off Wednesday.  The vet called me on Thursday and said "we've got a VERY faint positive ... like 'positive' on that tick test is 16 [to about 35] and Billy's is ... 16.  So it's a light case if that's what it is."

At that point I would have done ANYTHING to have it NOT be IMHA.  Sandra Slayton (and you'll see her posts on here) has been a friend of mine for YEARS ... long before we both gravitated to Dog dot com's board here.  I knew her when she had Hunter.  I knew what she went thru when she lost Hunter or IMHA/AIHA.  I knew how bad this disease could be and how ***fast*** it could hit.  I did NOT want it to be IMHA. 

So we grabbed at the "positive" tick test and the vet called doxycycline in to Walgreens for me (he's 45 minutes away) which is the typical protocol for tick disease.  Remember this is Thursday evening.  I started him on the doxy at suppertime.

Friday night when David got home from work at 8, Billy went to go greet David and STAGGERED.  We looked at each other and grabbed leash and purse and went to the emergency vet.  The PCV taken Tuesday late in the day had been 29.  Friday night it was EIGHT.  Single digit.  My dog was nearly dead.  His "PCV" had fallen twenty-one points in just those 2 days. 

That started our merry-go-round.  In Billy's case he had SIX transfusions (5 up at the U of FL at Gainesville where he stayed in ICU the most of the next month - home on and off).  As long as Billy was on the doxycycline he kept crashing over and over.  He'd get a transfusion, feel better and come home in a few days, then it would bobble around 24-26 and then a few days later the tail would stop wagging and he'd be crashing and back to Gainesville we'd go.

During that time they determined Billy's body was killing the red blood cells in the bone marrow (he had a bone marrow aspirate) and it was killing ALL the reticulocytes before they got TO the bloodstream and it was continuing to kill adult red blood cells.

Along the way they did an entire complete tick 'panel' (it's several hundred dollars and it took nearly THREE WEEKS to come back).  Billy did NOT have tick disease.  He had apparently been 'recently exposed' and his body had formed anti-bodies and it was likely THAT was what triggered the IMHA. 

His body saw the disease cells from the tick and formed antibodies to them to kill them/deal with them **as it should have**.  BUT ... then for some reason Billy's body saw the antibodies **IT HAD FORMED** and decided that they, too, were invaders.  Once all the antibodies had been killed the body further generalized and just kept killing other red blood cells. 

The loosely held theory in Billy's case was the doxycycline - which is **often used** in veterinary medicine to BOOST a dog's immune system, simply threw his body into a frenzy to get rid of blood cells.  ALL of them.  It's entirely possible it was the doxy that actually threw him into full-blown IMHA.  Because he was responding to the prednisone initially -- his PCV had gone from 20 to 29 in about 10 days.  That's pretty darned good.  It's possible his body literally went crazy with the immune "boosting' effect of the doxy and attacked the blood harder and faster.  The guess is that the whole 21 points his blood fell happened in that one day on doxy.

But doxy is TYPICAL to give when you suspect tick disease when you have a dog who is anemic.  My vets did NOTHING wrong.  I must stress that. 

 *****BUT FOR BILLY -- DOXYCYCLINE WAS A TOXIC TRIGGER*****  The tick bite was the initial problem ... what actually caused the body to react against that tick bite we'll never know other than the fact he was a mega allergy dog and it was HIGH allergy season.  But it was the doxy, in Billy's case, that triggered his 'relapse'.

Most regular or "allopathic" vets never EVER look for a trigger beyond vaccines (and they've been slow to even acknowledge vax as auto-immune triggers). 

Most vets don't bring it up -- in my own opinion much of that is because they just haven't been trained to think that way, and most of them don't even want to contemplate that something they gave they dog or sold could have caused a problem.  Vets today have been taught to diagnose and treat disease, or fix a problem surgically.  They have not been taught to think about "toxicity".  It's just not something that regular vet school prepares them for.

Johnny, given that your dog has relapsed I would tell you to think until your brain comes loose to try to figure out WHAT may possibly have triggered both the initial onset AND the relapse.

A friend of mine on this board is fond of saying "Idiopathic" is simply that they don't know what causes it and it's a way of "avoiding saying".  That's pretty darned true -- they really don't WANT to say what may or may not cause them. 

‘A couple of cautions here:

Chicken is SUPER **low** in iron – you can do much better with beef, lamb, particularly beef heart, liver, or whitefish (which is pretty high in iron actually).  Chicken also – to quote the Chinese TCVM stuff tends to increase inflammation … not that it’s an “allergen” it simply tends to steer the body to inflammation.  I hardly ever feed it at all.  We tend to be hardwired as humans to think “chicken” because beef is higher in cholesterol.  Dogs do NOT have cholesterol problems but there is so much more nutrition in beef, lamb, duck, whitefish than there is in chicken. Even turkey is better than chicken.

Vary the veggies – turnip greens, spinach, beet greens, kale and romaine – those are high in iron.    The pumpkin is good – but so is sweet potato and squashes generally. 

Ice cream – BE CAREFUL (and not for the reason you may think!!).  dairy tends to make the body not absorb the cyclosoporine and you’re already concerned about the dose.  You likely will be able to reduce it if the cyclosporine levels raise in the body and ice cream is going to work against you there.

What to use?  Try braunschweiger (it’s in the cold meat section of the meat aisle).  It’s “liver sausage” – already cooked.  You just cut off a slice, and I slice those wheels into 1/6ths and then press the pill into the braunschweiger – the dog will LOVE it and it’s liver and *high in iron*. 

Meat baby food also works (and you can use lamb, beef, veal – all high in iron).  No ham – too salty and too full of nitrates.

Thanks for the advise Callie.  To answer some of your questions....I'm not sure what her average HCT was before diagnosis.

When you say the Atopica dosage is alot considering she is also on prednisone (50mg) and azathioprine (37mg)....that's what I was thinking.  I've always heard that as other immunosuppresives are added the others can be lowered or discontinued.  Instead...when Tessy had a mild relapse the doctors at the university added 200mg of cyclosporine a day and upped her azath to 37 from 25.  It all really is confusing because no matter who you ask it seems everybody has a different opinion or answer.  I'm starting to go by what Dr. Dodds recommends because, like you said, she is one smart lady and I really think that if anybody knows what they're doing it'ld be her!

As far as figuring out what the trigger is....I really have no clue.  I'm keeping most treats and non-essential foods away from her for the time being.  The only other thing I can think of was the addition of aspirin and sucralfate about 4-5 days before her relapse.  She seemed to be doing well until I added those drugs 1 1/2 months into treatment.  Not sure if they might have played a role or not.  Maybe she got into something and I didn't see it.  It would have had to have been outside because the inside of the house has nothing that might trigger a relapse.  Overall...I'm just not sure what the trigger is.

Tessy's diet is going to get a changing in the really near future.  Isn't too much liver and red meats bad for the liver?  I will be adding some green leafy veggies and some more orange yellow veggies.  I'll have to add them slowly so she gets used to it.  As far as icecream goes....it isn't really icecream...it's a low fat yogurt icecream.  Is there any difference?

For the meantime....I have been racking my brain trying to find out what the trigger was.  I'll keep you all informed when my head explodes.

Thanks again for the advise.  It's great to have people who care out there.

Johnny & Tessy

Johnny&Tessy

When you say the Atopica dosage is alot considering she is also on prednisone (50mg) and azathioprine (37mg)....that's what I was thinking.  I've always heard that as other immunosuppresives are added the others can be lowered or discontinued.  Instead...when Tessy had a mild relapse the doctors at the university added 200mg of cyclosporine a day and upped her azath to 37 from 25.  It all really is confusing because no matter who you ask it seems everybody has a different opinion or answer. 

Billy was about 32 pounds when he started and he was never on more than 150 mg of cyclosporine and no more than 40 mg/day of pred.  No azathiaprene.

Johnny&Tessy

As far as figuring out what the trigger is....I really have no clue.  I'm keeping most treats and non-essential foods away from her for the time being.  The only other thing I can think of was the addition of aspirin and sucralfate about 4-5 days before her relapse.  She seemed to be doing well until I added those drugs 1 1/2 months into treatment. 

A lot of vets truly just shove drugs at the dog -- more and more and more. 

ABSOLUTELY -- sucrylfate was the first thing they took Billy OFF because it is **known** to inhibit the absorption of the cyclosporine.  Most of the vets here are using Pepsid or Zantac ... and Billy wound up on Prilosec (which is a 24 hr drug but they gave it to him twice a day just to keep the stomach "ok";). 

If the sucrylfate was added  and then a few days later the cyclosporine level wasn't enough (because she wasn't absorbing what she took) then that would have accounted for the partial relapse. 

But with regard to food -- don't worry about gaining weight.  The critical thing is to keep them eating and eating well.  These drugs tend to make them hungry and it's not that tough to get the weight down later if you have to.  The important thing is to keep them eating.

**DAIRY** -- yogurt is dairy.  Dairy is going to inhibit the absorption of the cyclosporine.  Use something else.  That was the other thing they made a huge point of early on with Billy.

Johnny&Tessy

Isn't too much liver and red meats bad for the liver? 

Liver is a dirty organ.  That liver you get in the grocery store is going to hold traces of everything filtered OUT of the liver of the animal that was killed (antibodiotcs and pesicides, etc.  Because the liver filters the blood.

Often when a dog or human are in liver failure they will lower the amount of *protein* -- not just red meat.  But this isn't a dog with liver failure.  This is a dog who is blood deficient so you need to HELP build that up. 

If you look in the list I gave you I put beef *heart* well in front of liver.  Heart is a good organ to give because it is, first of all, a clean organ.  It doesn't filter -- it's a muscle that pumps and essentially heart is good for the heart.  But the critical thing is you have to feed her the stuff that will help build the blood.  Stuff high in iron and blood builders. 

Chicken really doesn't have a lot of nutrition in it.  **particularly** not white meat.  Beef and lamb are probably the two best meats as far as being high in minerals and iron and the things the body needs.

Now I'm not advocating a super high protein diet -- I know a lot of people do them, but I'm not one of them.  But i *DO* use the meats with more nutrition like beef, lamb, whitefish and some turkey.  I'd use more lamb than I do but it's pricey.  When I do organ meat I tend to use heart and then a LITTLE liver occasionally. 

Johnny&Tessy

For the meantime....I have been racking my brain trying to find out what the trigger was. 

I find calendars extremely helpful.  Sometimes just going back thru receipts to know what happened when.  Put the calendar down and then look at it later.  Try to re-construct the weekends between Canadian Thanksgivng and the Holidays.  When did you use this or that?  When did you go away?  When was that weekend you wound up not going anywhere because the roads were too bad.  When did you have some repair done.

Just keep adding it to the calendar.

There are other stomach protectants that ARE ok to use.  Tagament, Pepsid, Zantac -- I'm pretty sure they're all sold in Canada.  Prilosec is really expensive -- but Billy had tummy issues a bit early on and I KNEW we had to keep him eating or he wouldn't make it.

Yogurt was a MAJOR disaster to have to deprive him of.  He LOVES yogurt In fact the first time I took him up to the University I took about 2 dozen containers of yogurt with him just so they'd be able to have some fun with it.    But nope -- it was one of the things they said "no" to just to get his body to absorb the cyclosporine  better. 

Have they checked her cyclo levels?  Here they do that about once a month -- it's pricey and it has to be sent away to the university to get the results, but it's what will tell them how well her body is using the cyclosporine.

Once they finally got Billy TO respond, eventually they had to lower the cyclosporine SIMPLY because he was absorbing it SO well that the levels were too high!!  So I can tell you -- it's seriously important not to use dairy and sucrylfate.  You need the drug to be used -- they're too harmful and too expensive for them not to be used well in the body -- if that makes sense.

Coopbay

The urinalysis showed blood in the urine but no crystals. The vet put Coop on Dicural. The pills are 136mg but he gets half a pill every day for the next 8 days. Then they said to wait 4-5 days after the meds are done and bring in another urine sample. What else can I give Coop? I know Callie mentioned something before but I can't remember what it was.

Welcome to the wonderful world of cyclosporine!!  I toldja to watch for blood in the urine!! *sigh*

D'Mannose -- AND cranberry.  Both have glucose -- and that helps the infection cells not 'stick' to the urinary tract.  It's not a "cure" but it will both help make them more comfortable and it will help avoid more infections.

This is yet another reason to make that TCVM appointment.  There is a really good Chinese herb called Ba Zhang that Billy took MANY times while he was taking the cyclosporine.  Ba Zhang is an herbal antibiotic and it really really helped control some of the utis.  Billy ran almost concurrent UTIs the whole time he was on cyclo -- we battled them CONSTANTLY.  He was literally on D-Mannose and Cranberry twice a day every single day.  He STILL take d-mannose!!

Get cranberry capsules -- give two twice a day.  Can be any decent brand.  The D-Mannose I got that I liked the best was NOW Brand -- get JUST the powder (it's a better value) -- it's sweet.  The darned stuff looks exactly like confectioner's sugar (tastes like it too!)  Give 1/2 teas. of the D-Mannose twice a day (you can increase that if you absolutely have to -- but it's spendy).

We had to do urinalysis every time we did a blood test -- just so I could catch the darned UTIs early.  And you have to BE SURE that the infection is gone before you stop the antibiotics.  That's where I learned so strongly to NOT discontinue the antibiotic before the infection is GONE -- otehrwise you run the risk of the dog getting resistant to the antibiotic (and then you can run out of antibiotics you can use FAST.).  It goes so he got them SO often that they would start him on cephalexyn (which is almost never ever used for UTIs) JUST because it was a less power-ful drug and Billy tolerated it well -- and sometimes that would kick it.  But you want them to use the LEAST Powerful drug first so you have somewhere to go if it doesn't stop the infection.

Thanks again for the advise callie.  I was just wondering about chicken heart.  Would that be a good food for a dog with AIHA?  It's much easier to get than beef heart.

Tessy has another appointment tomorrow.  I will be sending the blood off this time to get a full analysis done.  I just got a quick question regarding her next (first) med reduction.  Since most of her numbers with regards to sizes goes (mcv/mch/mchc/rdw/etc.) are all going within normal limits I was wondering if it would be best to reduce her azathioprine or her prednisone.  Her RBC/HGB/HCT are all stablizing off in the high 20's so I'm not sure what the best route would be.  Her platelets are very high so that also concerns me (near 1000).

Should there still be a reduction if there are spherocytes seen or if the retic numbers are higher than they should be etc. even if her HCT remains stable yet again.  Just sooooo much to think and worry about here in the next 24 hours.

Thanks,

Johnny & Tessy

I know you were saying that every case is diffrent and it depends on the chem numbers....I was just wondering if the RBC sizes would play a role in which to reduce first.

Thanks again,

Johnny & Tessy

Johnny&Tessy

I was just wondering about chicken heart.  Would that be a good food for a dog with AIHA?  It's much easier to get than beef heart.

Chicken heart is better than nothing and it's better than liver -- but call around and try to get someone to order the beef heart.  Don't bother to talk to just "someone" in the meat dept. -- ask to speak to the meat "manager" or the butcher.  Beef heart should be CHEAP.  I bought four pounds last weekend for $1.19 a pound NO JOKE.  down here senior citizens buy it LOTS because it's cheap and because it is good for you.  A bit tough but very good for you.   Trust me -- they don't throw them away at the slaughterhouse -- you just have to find someone who will order it knowing they WILL have a buyer.

Johnny&Tessy

Her platelets are very high so that also concerns me (near 1000).

I'm at work so I don't have no time to check your prior posts but is she taking aspirin?  Cyclosporine DOES make the blood very very thick -- and so if she's NOT on low dose aspirin you may want to tell the vet that you've read that some of the American vets (Arboretum in Chicago is VERY famous and you may even ask them if they want to email Dr. Dodds at Hemopet) are using a VERY low dose of aspirin simply to thin the blood a bit. 

As far as which drug to lower?  The vets will decide that.  I really don't know.  But I **WOULD** be very very VERY forthcoming to them about your financial situation and if you run the risk of not being able to afford her meds TELL THEM to lower the most expensive drug if you are honestly to that point where it's a huge concern.  Otherwise the vets will have their own way they want to wean it off.  I'm not a vet, Johnny -- I'm just a lady who has a dog who survived this who "learned a lot".

I know Billy's blood got SO thick it scared the crud out of me.  One day they were trying to get blood out of his front paws (blood draw #9999) and it coagulated BEFORE IT GOT TO THE TUBE!!!  No joke.  It clotted IN the needle.  I saw the tech hold up the syringe and take off the needle because they couldn't withdraw any more blood but were IN a vein and when she took off the needle there was a STRING of coagulated blood between the needle and syringe.  It clotted THAT fast.

I almost lost my lunch just thinking about it ...

But bottom line -- the vets will take a TON of things into consideration -- including Tessy's kidneys, liver, etc -- it's not a matter of which sized blood cells are what -- it's a matter of the whole package -- does that make sense?