Overwhelmed and don't know what to expect- just started Prednisone on Charlie

[Deb]

I just found this forum and there is so much info I am overwhelmed. Would appreciate any info/support you can provide.

My Charlie, a 50 lb Samoyed/shiba inu cross was diagnosed with chronic microcytic non-regenerative anemia in April. Further testing at a university vet hospital found lymphoma of the spleen. He underwent a splenectomy and they also found a leiomyosarcoma of the intestinal tract which they removed and got good margins. They feel they got all of the CA and thought this would reverse the anemia, it did not, despite 3 months of oral iron supplements and then an injection of iron.

In midDecember Charlie had 3 episodes of deep breathing and then collapsed. His platelet count was >1000 K/microliter, so we started him on an antiplatelet (his HCB was 7.7, HCT 22) and I made the 650 mile trip again to the university to try a blood transfusion. At this visit they did diagnose him with IMHA and decided not to transfuse but send off a vector panel and if this would be negative to start immunosuppression since Charlie was stable and chronic.

The vector results were to be delayed by greater than 2 weeks due to the Christmas holiday, so the decision was to start azathioprine instead of prednisone as Charlie has also been on remidyl long term and doesn’t do well off of this (prednisone and remidyl are contraindicated together).

Charlie was stable and doing about normal until I started the azathioprine. After about 4-5 days of treatment, he stopped eating and drinking and was quite weak. He got so dehydrated I took him into the local vet and he did IV fluids, and we made the decision to stop the azathioprine and remidyl and start prednisone and stomach protectants (sucralfate and famotidine) along with an appetite stimulant. That was on Friday and he has improved each day and I am hopeful….BUT…I am really concerned about the side effects of pred.

He is panting, and drinking like crazy which is to be expected, but I’m not getting any sleep at night as he needs to go out and pee every 2-3 hours. I worry about leaving him too long even though he has always had good bladder control, I have to rush home at lunch and after work to let him outside. I worry about his liver enzymes as they went way up with just a few days on the azathioprine (ALT 194, AlK P 655).

I am hopeful we can reduce the dose of prednisone to help with some of the side effects, but also know we can’t do this too quickly, but it is difficult not getting my sleep. I worry about infections without a spleen, .UTI, diabetes , hepatotoxicity, hair loss and muscle atropy with the prednisone. He already has severe hind leg muscle atrophy from osteoarthritis.

The more I read about this disease the more I’m confused as Charlie doesn’t seem to fit the mold with the chronic anemia he has had, most everyone has dogs with acute symptoms. I almost feel it is overkill to keep him on the prednisone for a long time, but I guess we have to see what the bloodwork shows.

Since Charlie is already an “old” dog at 15, I am more concerned about his quality of life as he has had a pretty long life already and really worry I am doing the right thing.

[Vally]

Hi Deb, welcome here and I’m so sorry to hear about Charlie and I know you’re exhausted right now. Yes the drinking and weeing is all because of the prednisone, panting too, it has a million side effects.

Is there anyone you could ask to let Charlie out during the day to give you a break from racing home?

Can you tell me all medication and doses Charlie is on now. Make sure you give the prednisone WITH food and the sucralfate 2 hours away from meds and food and famotide also away from other drugs to stop them blocking the drugs.

Azathioprine is a good drug but it can cause pancreatitis, I wonder if that’s what was happening with Charlie. Another excellent drug is Cyclosporine (Atopica). It’s much more expensive though, but it works by specifically targeting the cells doing the damage.

Don’t worry about liver damage right now. The drugs are doing that and when the prednisone can be reduced, the liver will recover. You can give Charlie Denamarin, which helps the liver to cope whilst on the drugs and also to repair damage, but Charlie’s liver enzymes although not normal, aren’t horrendous. If they get much worse, the drug is there and it works magically and quickly. You can also give a good quality milk thistle which helps the liver (it’s included in the Denamarin).

Ask anything Deb.

Vally

[Patrice]

Deb,
I understand your confusion. I went through this same confusion in 2007. Chance survived but it is a long and complicated story. You can read a brief description of this by going to Chance’s Story under Our Stories. I named this site in Chance’s memory.
https://www.secondchanceaihadogs.com/our-stories/chance

Your vet is clearly puzzled by this condition as it is unusual. I am not puzzled by it. And in fact we have successfully helped hundreds of owners on this forum with this condition.

I am going to ask you to get a second opinion from the vet that guided me to save Chance’s life. Dr. Dodds’ profession for over 30 years has been the treatment of canine AIHA, IMHA and bone marrow failure. She consulted with my vets and through her protocol we saved Chance’s life. Her organization is Hemopet and it is a not-for-profit.

To see her protocol go to this page and click on the picture of Dr. Dodds Immune-Mediated Hematological Disease and Bone Marrow Failure.
https://www.secondchanceaihadogs.com/hemopetresources

This will open a window with the protocol in it. You can click to make this full screen and print or save as you wish. This is the identical protocol that I used to save Chance’s life and is the one that hundreds of other owners have used since I first contacted Dr. Dodds in 2007. Vally can also input how valuable her advice and help is.

What was critical for Chance was the addition of Cyclosporine, or Atopica the brand name. You will see that mentioned on this protocol.

There are many things you have mentioned and asked about. We can discuss those a few things at a time. Right now it would be appropriate to have a second opinion. If you or someone in your family was very ill, you would want a second opinion, correct? This is no different and it will be a very inexpensive cost.

It is also very important to find some peace in your life with this. I know how upset you are, truly I can say that. But when Chance was this ill I knew that I had to compose myself and be there for him every day in a positive and loving way.

Being sad was a distraction that I did not have time for. I set that aside and became very focused on helping him. I have a human medical background so I bought a veterinary hematology textbook and studied it. With Jean Dodds’ help, my wonderful local vets and the information I gathered the picture got clearer to me what was happening medically. It made me feel more at ease.

There isn’t enough time for you to learn everything you need to know about this disease to be knowledgeable, but we can help you understand it better so you can make educated decisions about what your choices are. Making decisions without emotion is important. And when you make educated decisions there is no room for regrets. You will have made the best choice with the information you had available at the time.

I have great faith that you can be a great at home mom nurse. You will be successful and we can help you through this.
my best, patrice

[Vally]

Ha, we both answered at once. Here’s the link to contact Dr Dodds if you’d like to do that. I would 100% recommend it as it gives you contact with an expert. Once you’ve started the consultation, she answers quickly and you can just email her with any other questions. It’s basically a one-off fee. The link is the second box on the page.

https://www.secondchanceaihadogs.com/hemopetresources

Vally

[Deb]

Vally and Patrice,
Thank you for your quick and compasionate reply. You must be very special people to dedicate your time and resources to monitor and support others going through this rollercoaster of a disease.

You are right, I am exhausted, I have been dealing with the anemia and complications since March and more intensely in this last month with the diagnoses of IMHA.

Vally, I appreciate your response regarding medications as I am a pharmacist and you are correct with all your info/advice. Charlie is 23 kg, is on Prednisone 20mg twice daily (With FOOD!), famotidine 10mg twice daily- and I do give that with the pred, clopidogrel (anti platelet) 3/4 of 75mg tablet daily, sucralfate 500mg dissolved in water and syringed orally twice a day a good 2 hours after his other meds.

We did discuss using Atopica when I was at the university, but due to the high cost we decided to go with the azathioprine- (if we are able to use human medication, I can get these at cost). I have spent so much money this last year, I am trying to save where I can.

The only thing that we have not done that the university did discuss was doing a bone marrow biopsy. I declined because I have decided that I would not aggressively treat with chemo if something showed up and biopsy is also painful. This last Dec visit he had another ultrasound of the abdomen which was clear and echo of the heart which was normal. So at this point, the veterinarians are at a loss for an explanation, but I just want to improve his quality of life and not make him and myself miserable in the process.

It might be a good idea Patrice for me to reach out to Dr. Dodd. I notice you mentioned a one time fee, is that for the inital consultation…what about followup labs and info? I have talked to my vet today after posting and the vector labs all came back negative, and he is talking about at the end of the week to recheck labs and start the prednisone taper by 50% if the HCT is up. On Thurs last week when he checked it and Charlie was critical and dehydrated it was 35% (thinks this was concentrated due to the dehydration).

I think that this is a very confusing, complicated, and unusual presentation of IMHA, so it is very difficult for me to know if we are doing all the right things.

Thanks again for being there and willingness to help.

[Vally]

Deb, first of all, Atopica is Cyclosporine (a human drug – used to prevent organ rejection in people who have received a transplant, so maybe you can get this). I was getting a prescription from my vet and taking it to a chemist to have filled. That was the first time I knew that pharmacists filled vet prescriptions. I remember ringing the chemist to make sure they would fill it, they said yes. When I went in to have it filled, I double checked again, yes. Then when ready, they called out Bingo Dal Pra, gave me a giggle. Live and learn. So perhaps that’s the way to go then.

Dr Dodds will offer her advice for her consultation fee. You can send to her all lab works you have and details of what’s happening and she’ll review them. I’m in Australia. She reviewed my boy’s lab work. I know she will recommend what Patrice has already suggested, as that’s her protocol to treat, but it’s fabulous to have her on your side as I had to reach out a number of times for different things, tapering, specific problems, liver values. My vet suggested one time, how to taper cyclosporine when Bingo was in remission, but I knew she KNEW this disease and in fact I changed the way I tapered the drugs to her method. She knows the drugs too and can suggest alternates. I just know I was glad to have her on my side.

With reducing prednisone, in order to lower the risk of relapse, we recommend a reduction of no more than 25-33% over a minimum of 2-3 weeks. See:

https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction

I know you’ll be keen to get Charlie off the prednsione, but it’s just better not to rush it – Bingo relapsed twice, and it meant that we had to go back to “GO” again and go back to high dosing of the prednisone all over again.

Totally agree with NOT doing the biopsy. My specialist told me that it was an option, but all it would do would be to answer questions, it didn’t change the treatment plan and in fact it is hard on the dog.

Regards, Vally (Angel Bingo and the new pest, Saba)

[Deb]

Hi Vally, thanks for the reply. I did ask at the vet college about using the human cyclosporin instead of Atopica and was told that they have tried this in the past and have not had good results, has to do with the bioavailability of the drug and monitoring, so if we were to do this drug the Atopica is the way to do it.

With Dr. Dodd did you have to pay for each time you reached out to her for advice after the initial consultation? I did read her protocol and it does mention prednisone 2-3mg/kg for 5-7d therapy and then reduced weekly by 1/2 and maintain for at least 6 weeks.

I’m thinking to see what his next bloodwork will show the end of this week after being on the prednisone for 7 days. Since he is more chronic than acute I’m thinking that we will be able to taper easier. My vet is pretty much doing as she has listed in her protocol so not sure what additional info she would be able to provide, especially since we have had a university internal medicine on the case also.

Exactly why I didn’t do biopsy as it would not have changed my treatment plan either. Sometimes you chase trying to get answers but in the long run it doesn’t affect the outcome and just costs more.

Not totally sure on a good supportive diet for Charlie. I was doing the hamburger and rice to get him to eat and now am mixing with his regular food and he seems to be eating pretty good, but thinking he might benefit from some fish oil for inflammation. I did see some type of diet info on Dr. Dodd site…do you fix a special diet for your dogs?

[Patrice]

Deb,
What is happening to Charlie is not the same conditions as IMHA or AIHA.

Spelled out, Immune mediated hemolytic anemia and autoimmune hemolytic anemia, you see a common word: hemolytic. Hemolysis means the destruction or rupturing of a red blood cell.

Anemia is a shortage of red blood cells that leads to poor oxygen delivery to body tissues. So anemia is not the disease, it is the symptom of poor body oxygenation due to the loss of red blood cells. So there could also be a state of anemia if a dog was in a serious car accident or was bleeding during a surgery.

Mediated means assisted or caused by.

The other describing terms, immune and autoimmune, refer to the body’s protective system and autoimmune means attack on “self.” So autoimmune or immune mediated hemolysis means the destruction of red blood cells in circulation.

Hemolytic anemia leads to many RBC being destroyed in the blood vessels, scattering debris into the blood and plasma, rapidly altering the homeostasis of the circulatory system. This can lead to dangerous clotting and organ failure. That is why autoimmune or immune mediated hemolytic anemia are so very serious and why those conditions are considered an emergency.

So all these words together mean the destruction of red blood cells as caused or mediated by the immune system. The difference is that auto tends to be considered a primary cause or the cause is unknown.

Immune mediated means that there is one or more triggers activating the immune system to attack RBC. For many years all of these conditions were considered autoimmune, but now, more often vets and academics use the term immune mediated to indicate that there is some outside cause for the immune system to go haywire. They just need to find those causes.

Let’s look at an easy to understand immune mediated trigger. Tick diseases insert some form of bacteria or spirochete into the body. Sometimes these insert themselves inside the red blood cell so they can reproduce and multiply. The immune system sees these invaders inside the RBC and decides that it must attack them. But it also destroys the red blood cells! This is immune mediated hemolytic anemia. If you treat the tick disease by giving doxycycline, you hopefully can stop the hemolytic anemia.

There are many many triggers and usually in dogs there will be several triggers that combine to set off the immune mediated anemia. That’s why a comprehensive history is so critical. Often these dogs tend to have something in their genetic makeup that make them more prone to expressing autoimmune disease. Environmental triggers contribute along with things like viruses, parasites, sex hormones. All stirred up by “stress” which is the biggest contributor to autoimmune disease.

So hopefully now you understand the terms AIHA and IMHA.

So let’s look at bone marrow failure. There are various terminologies that describe more specifically what and where the actual failures are, but for now just think of this as the bone marrow is unable for some reason to send out new RBC to the body’s blood circulatory system.

At some point in his life Charlie was quite able to make new RBC. But sometime earlier this year he began to have trouble with this process. Why and when?

Jean Dodds has been studying and treating this bone marrow failure in dogs for more than 30 years. While academics and other researchers can point to multiple conditions that can cause bone marrow failure, Dr. Dodds has seen first hand that most dogs she has treated with this condition have a similar autoimmune attack WITHIN the bone marrow that leads to the destruction of precursor cells in the marrow. This is maturation arrest. In fact she knows that this is quite common in dogs.

But yet many vets in the world do not understand this. There can be other rarer causes of this as researchers and vets will point out, but for sure while I have seen this many many times in the dogs that need help on our website, I have very rarely seen any of these more obscure causes. And I have seen vets fumble with this condition, not understanding it well and unable to think clearly about the application of appropriate protocols. They get lost in doing too many tests and continue to look for an elusive cause. This most especially happens at teaching universities where odd cases make for great research and interesting papers. The more testing the merrier, at great expense to the owner. I have come to the conclusion that any qualified vet, and especially those with a background of curiosity and dedication to the field, develop amazing protocols that really save lives. My country vet is far more advanced in her treatments than some of these multi-million dollar vet hospitals.

For Chance his genetic background definitely contributed. First was the expression of complex canine atophy at a young age (canine inhaled allergies) that resulted in serious skin problems. We learned that he had gradually developed hypothyroidism, another very serious condition that contributes to bone marrow failure. He also had a digestive disorder and inherited the inability to properly digest and utilize vitamin B12. He developed a condition called extramedullary hematopoiesis, the making of blood in another organ other than the bone marrow. This growth was on his spleen. We commonly make blood in utero with the spleen before we fully develop our bone marrow. So the body has a place to fall back on to make blood somewhere else.

The bone marrow is a living tissue and it is extremely active our whole life, each day, making new cells. It never stops and it controls the amount of RBC it needs to make by monitoring the body signals when tissues complain they are not getting enough oxygen.

This graphic is a simplified look at the multiple steps that are involved in the maturation of all the cell types that are created in the bone marrow. There are many steps involved that are not shown.
https://www.secondchanceaihadogs.com/AIHA_Terms/hsc-hematopoietic-stem-cells

So at some point in Charlie’s life he slowly stopped making RBC even when the body demanded it. All the RBC that he made in the last 120 days that were in circulation were still ok, they had been made properly, so you didn’t notice he was slowly becoming anemic. It is a very gradual loss of RBC as they age out, a little each day, but not enough to be a dramatic change.

So I hope you can begin to understand that this condition is totally different than hemolytic anemia. It isn’t dangerous, there are no risks of clots. The integrity of the blood vessels is still ok, there isn’t debris in circulation. It’s a very slow loss over time.

But yet profound bone marrow failure is far more serious and deadly because if you can’t figure out how to help your dog make RBC again, they will certainly become extremely ill and maybe even die.

So now I hope you understand that this destruction is going on inside the bone marrow and that is a very isolated part of the body. How to stop the damage?

This is how Dr. Dodds began to study canine hematology. Her first job out of veterinary college included a position with NYS where she was in charge of the human blood supply at a time when AIDs and blood safety were becoming important. She decided, as a veterinarian doctor with a specialty in hematology, that she would change her career and begin providing blood services for dogs. There was no looking back.

She began seeing these dogs with the same symptoms, profound bone marrow failure at the precursor cell stage. She calls them pluripotent stem cells (master cells.) She was watching with interest the new heart transplant surgeries and the treatments human doctors were developing to prevent rejection of the organ. Because prednisone had so many terrible side effects they were looking for some other drug to use. This is when cyclosporine was first introduced. It’s main function was to stop the activity of the killer T-cells of the immune system from attacking the new transplanted organ. It is still used today.

Dr. Dodds picked up on this concept for dogs. She rightly thought, why not try using cyclosporine in dogs to stop the immune system from destroying red blood cells or killing off pluripotent stem cells! And it worked extremely well. She eventually developed a pulse dosing protocol (you can find this in that protocol I linked you to) for the cyclosporine. After a while veterinary pharmaceuticals decided to do trials with cyclo, but for canine allergies, not autoimmune disease. They discovered that dogs actually did fabulously with cyclo and so they marketed it as Atopic, for atophic allergies.

So that is the key to stopping the destruction in the bone marrow, high loading doses of cyclosporine, in Monday through Friday (Saturday and Sunday off) pulse dosing for approximately 3-5 week cycles. The doses are high, it wasn’t exactly pleasant for Chance, but I had no choice. He was going to die if I didn’t do something and Dr. Dodds was such a famous vet that I felt compelled to give this a go. Within 4 weeks, my vet came into the exam room with the CBC and a smile on her face. Chance began to become regenerative again. It was tiny but it showed me immediately that he was going to live. His poor body was in a terrible state from months of high dose prednisone, but Jean never gave up helping me and my vets were just delighted to be working with her. They were just stunned that this protocol worked so well.

It took Chance a long time to recover his body condition. But inside his body it was beginning to heal and he acted like he felt better. I didn’t care about the cost of his medications. I could see he was going to live.

I am unhappy that you were talked out of the cyclosporine because of the cost. I hope you will reconsider this decision. I think it is critical to gradually reduce the prednisone and aza and switch over to cyclosporine as the main immunosuppressive drug.

Dr. Dodds will look at your lab workups and will probably recommend her protocol. She may have more advice about the medications you are currently using.

My experience is that aza can lead to profound bone marrow suppression over time and thus it could actually be part of the reason why the bone marrow can’t respond any more. Aza is a chemotherapy drug. It is designed to suppress and stop the reproduction of rapidly growing cells. Great if you are fighting cancer. But our skin and our bone marrow consist of rapidly growing cells! From start to finish you can push out new RBC in about 7 days. White blood cells and platelets have an even shorter growth process.

I truly hope you also understand why I don’t recommend a bone marrow biopsy. You already know that Charlie is not making RBC and there is a pretty good chance that it is autoimmune destruction of the pluripotent stem cells. The test will only confirm what you already know, he’s not making blood, it will not help change the treatment protocol. The test requires anesthesia and sample collection from the shoulder or hip that can be quite invasive. It will leave Charlie sore and struggling to recover from the anesthesia. Chance had this done and I regretted it, it told me nothing and it didn’t improve his treatment protocol. It was time for me to see another vet.

Put the money you save by not having that test towards future blood transfusions and atopica.
my best, patrice