Am I being crazy??

[Trish]

So, Max had his PCV check today. It’s not really changed since last week – hasn’t gone down, but hasn’t really gone up. His official number last week on Wed was 39%. His manual PCV number today is 40%. Is that okay that he has not gone up significantly in a week, now that he is finally regenerating? He went up so fast from July 7th to the 15th – jumped from 24 to 39!

The specialist we are seeing did lower his Prednisone dosage by 20% last week after he got up to 39 (he was taking 40 mg, now he’s taking 30 mg). My vet is waiting on lab results on possible bladder infection, but his x-rays did not show stones (a concern with him). Am I crazy for freaking out over no change in PCV? I am just worried that he was going up so steadily, that something is stalling him now. His normal PCV was in the mid 50’s. Boy, this disease makes you nuts.

[Brigitte]

Hi Trish,
welcome to the crazy club! We are all paranoid and more worried than any other pet parents.This disease scars us forever. I think it is completely normal that Max’s PCV has stayed the same. You can not ask for a big jump like that every week. A bladder or ut infection could sure be the reason that he would not increase. But I am sure you would be aware if that would be the case, he would strain, be in pain and not feeling well. Good that you have it checked out, you never know. How is Max behaving? Is he acting close to normal? A PCV of 39 is sure great and you should be really happy about that. Forgive me, I have no idea if Max is on any supplements. Is he taking petinic? Is he on a thyroid supplement? That could possibly help. Lowering the prednisone by 20% is safe and that should not be a problem at all. I hope the urine analysis will come back clear. If it doesn’t it is something that can be treated with antibiotics. It is something that happens a lot and is very treatable.
Try and relax, be happy the PCV did not go down and celebrate that Max is on the up and up!
Best wishes,
Brigitte

• This reply was modified 11 years, 3 months ago by admin.

[Linda]

Hi Trish. I am dealing with a UTI infection with my pup, Sadie. Your situation is totally different, but everyone here stressed a urine culture for her. I would have your vet do this with Max ASAP, just in case.

Congratulations on the PCV though. He’s on his way!

I take it he’s on cyclosporine and that is not being weaned on that yet? It sounds like your vet is on the ball. This is key and makes this crazy roller coaster more tolerable.

And you are NOT crazy. As Brigitte says, we ALL are in the same page and do the same thing, questioning every move at times.

Hang in there. You really are obviously doing a great job!

Love and hugs, Linda and Sadie

[Patrice]

Trish,
This is great news about Max! This value, 40%, is perfectly normal.

Let me see if I can explain this in a way that you will understand. You are concerned that he didn’t rise much from last week, only going from 39 to 40%.

Imagine you have a glass and you want to fill it with water. You go to the tap, turn it on full and fill the glass. You set it down and forget that it is there for a few days. You see it and realize a little water has evaporated. You want to top the glass up a little so you go back to the tap, run the water slow and carefully refill the glass. Just a little bit of water does the trick.

This is what it is like for our bodies when we are not anemic and perfectly healthy. We only replace a small number of old red blood cells each day. RBCs live about 120 days, wear out, are destroyed and the parts are recycled or eliminated. This destruction of old RBCs and production of new RBCs happens every day of our lives.

So a healthy dog or human usually has about, at the lowest normal value, 5.5 million RBC! We may replace about 1-2,000 a day. Small change, right? So, on a CBC, you will see this as a reticulocyte value (the measure of immature RBCs in circulation) and the number will hover right around, plus or minus, 60,000 absolute or about 1% of 5.5 million.

Let’s see what happens a dog has AIHA IMHA, (hemolytic anemia), and they are destroying red blood cells rapidly.

Let’s go back to the glass. You walk over to the tap and fill the glass to the top. There, you think, done. But there is a hole in the bottom of the glass. As soon as you fill it, the level goes down. You go back to the tap and try to top off the glass again. Hmm, what’s happening here? Soon you have the tap wide open but still cannot keep the glass full. Unless this hole is plugged you will never keep the glass full.

When this happens in hemolytic anemia we call this reticulocytosis. This is a huge response by the bone marrow to replace all the destroyed mature RBCs with immature RBCs in hopes of increasing the amount of oxygen available to the body cells. And that is what drives this excess production, a state of anemia. The kidneys receive a message from the body cells, “Hey! Get some more oxygen out here to us right away!” The kidneys send a special hormone, erythropoietin, to stimulate the bone marrow to make new RBC. It won’t stop doing this until the body cells stop complaining. This reticulocyte value can be extraordinarily high, as much as 550,000 absolute and 3-5%!

Contrarily, if a dog has severe anemia, for instance a HCT / PCV of 18%, and there is a very tiny number of reticulocytes (less than <60,000 ) then you have a state of non-regenerative anemia. The bone marrow may be getting a message from the kidneys to make reticuloyctes, but nothing is happening. This is a very serious condition and requires a complex treatment.

The value of reticulocytes is considered the “gold standard” for evaluating anemia. Clinicians should be monitoring this value carefully to see how the body is responding to treatment and what it is doing to attempt to heal itself.

You’ve done a great job with Max! Right now Max does not have anemia, his HCT is within a normal range of around 38-55%. If you were to look at the CBC you would see exactly what I have mentioned, a reticulocyte value of about 60,000 absolute, about 1% (+ or -). If you want me to look over the latest CBC, upload it on the Urgent Advice page.

If he stays stable you will not see this rapid increase from week to week. It will level out to Max’s normal value, where his body is comfortable. His body has decided it is all better.
my best
patrice

[Trish Aquilino]

Thank you for talking me off the ledge, ha! And thank you so much for the explanations, there is so much to learn about this condition. We are super pleased that he hasn’t gone down, for sure. Just was worried for a bit that his progress has slowed, but that explanation, Patrice, is extremely helpful and makes sense to me. I will definitely upload his latest CBC. Linda, they are a definitely doing a urinalysis – does that include a culture? I am still learning some of this terminology. I used to think I was really up to speed on this sort of thing, but IMHA has introduced me to a whole new language, sadly!

He is on pred, which is being reduced, mycophenolate, which has not been reduced at all, plavix, b12 injections, prilosec as needed, and his normal dose of thyroxine. He is also on a reduced dosage of his fluoxetine (for anxiety). He takes potassium citrate and b6 for oxalate stone condition, as well as glucosamine. I am giving him slippery elm to help ward off any stomach issues, which, thankfully has been working, as he normally has a very sensitive gut.

[admin]

Hi Trish

No, you are not crazy, just paranoid like the rest of us! And quite right too. Better to be over-cautious.

Couldn’t agree with Patrice more – the reticulocytosis slows down as they get into normal levels. This happened with Worzel too – you just don’t see the massive increases as they get better. Bearing in mind Worzel is a greyhound – they have very high PCV & RBC levels, hence make great blood donors – his “normal” PCV is 63 ish, his increases were much, much slower after he reached the 40 mark. During the drug weaning process (azathioprine in his case), he slowly increased & he is now back to always being over 60, which is normal for him. It took a long time as we were very cautious to avoid a relapse! I would say again, take the prednisone weaning slowly & carefully as per this link: https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction/

When you get to the lowest possible dose of prednisone (hopefully NIL) then you can start reducing the mycophenolate – that drug, like azathioprine, can suppress the bone marrow & we saw further increases with Worzel each time we reduced the drug. I am so boring I have a spread sheet of the figures to prove that!

Brigitte is right – infection hampers them too – we had a recent problem with Worzel – a severe GI tract infection leading to malabsorption – his PCV dropped to 55 & I was very worried as that is low for a greyhound. It shows that any infection will cause a drop in PCV for our dogs, so we have to be on the ball and get any infection treated as soon as possible – UTIs are so common with our IMHA dogs & easily treated, so don’t worry.

I have looked at Max’s blood results – all looking so much better on the later test on the anaemia front, Trish. BUT I am highly suspicious of an infection as his neutrophils (they are the things that attack bugs) are a bit high & so are his monocytes – monocytes indicate inflammation too. So let’s hope the vets get to the bottom of this possible UTI. As Linda mentioned, Sadie has a very nasty UTI & has been on Baytril & minocycline – we checked both these drugs for safety with IMHA dogs with Dr Jean Dodds & she was happy with those choices. Of course, it’s always better to find out from a culture exactly which bug it is, then treat with an antibiotic known to be effective against that particular bug. But please feel free to ask if you are in any doubt about the antibiotic they chose. You already know the three no-no groups. Many of us have used doxycycline, so we also know that is OK to give our pups. Pop a quick message on here if you are worried about anything.

So, maybe this infection is holding Max back a little, that certainly happens. Don’t expect huge increases any more. In our experience, it slows down at this stage in treatment. At one time, I would have paid a million pounds for Worzel to be in the normal range!

Your vet has done a superb job with the treatment & all the right blood tests & blood smears too. I note the presence of rouleaux, so am glad to see the plavix – I am the site nag about clotting issues, but your vet has already spotted it & done the right thing.

Have you ever tried sucralfate? In my opinion it’s much better than prilosec. It has to be given well away from all the other medications as it will prevent their absorption & we can’t risk that. Worzel was in a lot of pain with his tummy, so we added sucralfate in & he never looked back. In view of Max’s sensitive tummy, I would give him some. Here’s some information:
https://www.secondchanceaihadogs.com/AIHA_Terms/sucralfate/

Let us know how you get on – Max is in the best possible hands with a Mum like you

Love & hugs
Sheena & the boys xxxxx

[Trish Aquilino]

Sheena, I was worried about possible infection from that last CBC too, why would our specialist not bring it up? Or our regular vet for that matter? I can’t tell you enough how much help you all have been in such a short amount of time. And he’s been on the Plavix since 6/23, should he get a bigger dose since now there is Rouleaux being seen?

[admin]

Hi Trish

I would definitely bring it up. The most likely & most simple cause is an infection, but it’s not a 100 % certainty. Neutrophils are the things that protect us from infection & when you see pus on a wound for example, or pus in wee, that’s neutrophils doing their job killing off the baddies forming lovely pus! There are other causes of high neutrophils though – corticosteroids & IMHA for example. so I can’t be certain. However, my suspicion is infection, especially as you already suspect a UTI. There’s a lovely explanation here:
http://www.2ndchance.info/dxme-Neutrophils.htm

( Don’t worry about understanding this next bit too much – Your lab haematologist will be able to look at this in conjunction with band neutrophils, mature/immature neutrophils & possible left-shift & give you an explanation as to what else it could be if it’s not infection – I get a bit boggled with all this myself!)

The Plavix (clopidogrel) dose should be OK as I imagine they’ve given you the correct dose straight away at diagnosis, then checked Max’s clotting time. Just check the dose if your vet if you are not sure or worried. According to
http://www.vetbook.org/wiki/dog/index.php/Immune-mediated_hemolytic_anemia
the clopidogrel dose should be 0.5 – 1.0 mg/kg daily.
You don’t want to overdo it either, as you then get a risk of bleeding. Happy medium.
These clotting problems occur at onset of illness & you just continue the Plavix until there are no more rouleaux, spherocytes etc. seen on the blood smear – they would have been there since the beginning.

Hope I haven’t confused you – this is such a complicated thing to deal with. Get back to me a.s.a.p. if I’ve not explained things properly!

Love Sheena xxxxx

[Trish]

So, Max had his PCV check today. It’s not really changed since last week – hasn’t gone down, but hasn’t really gone up. His official number last week on Wed was 39%. His manual PCV number today is 40%. Is that okay that he has not gone up significantly in a week, now that he is finally regenerating? He went up so fast from July 7th to the 15th – jumped from 24 to 39!

The specialist we are seeing did lower his Prednisone dosage by 20% last week after he got up to 39 (he was taking 40 mg, now he’s taking 30 mg). My vet is waiting on lab results on possible bladder infection, but his x-rays did not show stones (a concern with him). Am I crazy for freaking out over no change in PCV? I am just worried that he was going up so steadily, that something is stalling him now. His normal PCV was in the mid 50’s. Boy, this disease makes you nuts.

[Brigitte]

Hi Trish,
welcome to the crazy club! We are all paranoid and more worried than any other pet parents.This disease scars us forever. I think it is completely normal that Max’s PCV has stayed the same. You can not ask for a big jump like that every week. A bladder or ut infection could sure be the reason that he would not increase. But I am sure you would be aware if that would be the case, he would strain, be in pain and not feeling well. Good that you have it checked out, you never know. How is Max behaving? Is he acting close to normal? A PCV of 39 is sure great and you should be really happy about that. Forgive me, I have no idea if Max is on any supplements. Is he taking petinic? Is he on a thyroid supplement? That could possibly help. Lowering the prednisone by 20% is safe and that should not be a problem at all. I hope the urine analysis will come back clear. If it doesn’t it is something that can be treated with antibiotics. It is something that happens a lot and is very treatable.
Try and relax, be happy the PCV did not go down and celebrate that Max is on the up and up!
Best wishes,
Brigitte

• This reply was modified 11 years, 3 months ago by admin.

[Linda]

Hi Trish. I am dealing with a UTI infection with my pup, Sadie. Your situation is totally different, but everyone here stressed a urine culture for her. I would have your vet do this with Max ASAP, just in case.

Congratulations on the PCV though. He’s on his way!

I take it he’s on cyclosporine and that is not being weaned on that yet? It sounds like your vet is on the ball. This is key and makes this crazy roller coaster more tolerable.

And you are NOT crazy. As Brigitte says, we ALL are in the same page and do the same thing, questioning every move at times.

Hang in there. You really are obviously doing a great job!

Love and hugs, Linda and Sadie

[Patrice]

Trish,
This is great news about Max! This value, 40%, is perfectly normal.

Let me see if I can explain this in a way that you will understand. You are concerned that he didn’t rise much from last week, only going from 39 to 40%.

Imagine you have a glass and you want to fill it with water. You go to the tap, turn it on full and fill the glass. You set it down and forget that it is there for a few days. You see it and realize a little water has evaporated. You want to top the glass up a little so you go back to the tap, run the water slow and carefully refill the glass. Just a little bit of water does the trick.

This is what it is like for our bodies when we are not anemic and perfectly healthy. We only replace a small number of old red blood cells each day. RBCs live about 120 days, wear out, are destroyed and the parts are recycled or eliminated. This destruction of old RBCs and production of new RBCs happens every day of our lives.

So a healthy dog or human usually has about, at the lowest normal value, 5.5 million RBC! We may replace about 1-2,000 a day. Small change, right? So, on a CBC, you will see this as a reticulocyte value (the measure of immature RBCs in circulation) and the number will hover right around, plus or minus, 60,000 absolute or about 1% of 5.5 million.

Let’s see what happens a dog has AIHA IMHA, (hemolytic anemia), and they are destroying red blood cells rapidly.

Let’s go back to the glass. You walk over to the tap and fill the glass to the top. There, you think, done. But there is a hole in the bottom of the glass. As soon as you fill it, the level goes down. You go back to the tap and try to top off the glass again. Hmm, what’s happening here? Soon you have the tap wide open but still cannot keep the glass full. Unless this hole is plugged you will never keep the glass full.

When this happens in hemolytic anemia we call this reticulocytosis. This is a huge response by the bone marrow to replace all the destroyed mature RBCs with immature RBCs in hopes of increasing the amount of oxygen available to the body cells. And that is what drives this excess production, a state of anemia. The kidneys receive a message from the body cells, “Hey! Get some more oxygen out here to us right away!” The kidneys send a special hormone, erythropoietin, to stimulate the bone marrow to make new RBC. It won’t stop doing this until the body cells stop complaining. This reticulocyte value can be extraordinarily high, as much as 550,000 absolute and 3-5%!

Contrarily, if a dog has severe anemia, for instance a HCT / PCV of 18%, and there is a very tiny number of reticulocytes (less than <60,000 ) then you have a state of non-regenerative anemia. The bone marrow may be getting a message from the kidneys to make reticuloyctes, but nothing is happening. This is a very serious condition and requires a complex treatment.

The value of reticulocytes is considered the “gold standard” for evaluating anemia. Clinicians should be monitoring this value carefully to see how the body is responding to treatment and what it is doing to attempt to heal itself.

You’ve done a great job with Max! Right now Max does not have anemia, his HCT is within a normal range of around 38-55%. If you were to look at the CBC you would see exactly what I have mentioned, a reticulocyte value of about 60,000 absolute, about 1% (+ or -). If you want me to look over the latest CBC, upload it on the Urgent Advice page.

If he stays stable you will not see this rapid increase from week to week. It will level out to Max’s normal value, where his body is comfortable. His body has decided it is all better.
my best
patrice

[Trish Aquilino]

Thank you for talking me off the ledge, ha! And thank you so much for the explanations, there is so much to learn about this condition. We are super pleased that he hasn’t gone down, for sure. Just was worried for a bit that his progress has slowed, but that explanation, Patrice, is extremely helpful and makes sense to me. I will definitely upload his latest CBC. Linda, they are a definitely doing a urinalysis – does that include a culture? I am still learning some of this terminology. I used to think I was really up to speed on this sort of thing, but IMHA has introduced me to a whole new language, sadly!

He is on pred, which is being reduced, mycophenolate, which has not been reduced at all, plavix, b12 injections, prilosec as needed, and his normal dose of thyroxine. He is also on a reduced dosage of his fluoxetine (for anxiety). He takes potassium citrate and b6 for oxalate stone condition, as well as glucosamine. I am giving him slippery elm to help ward off any stomach issues, which, thankfully has been working, as he normally has a very sensitive gut.

[admin]

Hi Trish

No, you are not crazy, just paranoid like the rest of us! And quite right too. Better to be over-cautious.

Couldn’t agree with Patrice more – the reticulocytosis slows down as they get into normal levels. This happened with Worzel too – you just don’t see the massive increases as they get better. Bearing in mind Worzel is a greyhound – they have very high PCV & RBC levels, hence make great blood donors – his “normal” PCV is 63 ish, his increases were much, much slower after he reached the 40 mark. During the drug weaning process (azathioprine in his case), he slowly increased & he is now back to always being over 60, which is normal for him. It took a long time as we were very cautious to avoid a relapse! I would say again, take the prednisone weaning slowly & carefully as per this link: https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone-dose-reduction/

When you get to the lowest possible dose of prednisone (hopefully NIL) then you can start reducing the mycophenolate – that drug, like azathioprine, can suppress the bone marrow & we saw further increases with Worzel each time we reduced the drug. I am so boring I have a spread sheet of the figures to prove that!

Brigitte is right – infection hampers them too – we had a recent problem with Worzel – a severe GI tract infection leading to malabsorption – his PCV dropped to 55 & I was very worried as that is low for a greyhound. It shows that any infection will cause a drop in PCV for our dogs, so we have to be on the ball and get any infection treated as soon as possible – UTIs are so common with our IMHA dogs & easily treated, so don’t worry.

I have looked at Max’s blood results – all looking so much better on the later test on the anaemia front, Trish. BUT I am highly suspicious of an infection as his neutrophils (they are the things that attack bugs) are a bit high & so are his monocytes – monocytes indicate inflammation too. So let’s hope the vets get to the bottom of this possible UTI. As Linda mentioned, Sadie has a very nasty UTI & has been on Baytril & minocycline – we checked both these drugs for safety with IMHA dogs with Dr Jean Dodds & she was happy with those choices. Of course, it’s always better to find out from a culture exactly which bug it is, then treat with an antibiotic known to be effective against that particular bug. But please feel free to ask if you are in any doubt about the antibiotic they chose. You already know the three no-no groups. Many of us have used doxycycline, so we also know that is OK to give our pups. Pop a quick message on here if you are worried about anything.

So, maybe this infection is holding Max back a little, that certainly happens. Don’t expect huge increases any more. In our experience, it slows down at this stage in treatment. At one time, I would have paid a million pounds for Worzel to be in the normal range!

Your vet has done a superb job with the treatment & all the right blood tests & blood smears too. I note the presence of rouleaux, so am glad to see the plavix – I am the site nag about clotting issues, but your vet has already spotted it & done the right thing.

Have you ever tried sucralfate? In my opinion it’s much better than prilosec. It has to be given well away from all the other medications as it will prevent their absorption & we can’t risk that. Worzel was in a lot of pain with his tummy, so we added sucralfate in & he never looked back. In view of Max’s sensitive tummy, I would give him some. Here’s some information:
https://www.secondchanceaihadogs.com/AIHA_Terms/sucralfate/

Let us know how you get on – Max is in the best possible hands with a Mum like you

Love & hugs
Sheena & the boys xxxxx

[Trish Aquilino]

Sheena, I was worried about possible infection from that last CBC too, why would our specialist not bring it up? Or our regular vet for that matter? I can’t tell you enough how much help you all have been in such a short amount of time. And he’s been on the Plavix since 6/23, should he get a bigger dose since now there is Rouleaux being seen?

[admin]

Hi Trish

I would definitely bring it up. The most likely & most simple cause is an infection, but it’s not a 100 % certainty. Neutrophils are the things that protect us from infection & when you see pus on a wound for example, or pus in wee, that’s neutrophils doing their job killing off the baddies forming lovely pus! There are other causes of high neutrophils though – corticosteroids & IMHA for example. so I can’t be certain. However, my suspicion is infection, especially as you already suspect a UTI. There’s a lovely explanation here:
http://www.2ndchance.info/dxme-Neutrophils.htm

( Don’t worry about understanding this next bit too much – Your lab haematologist will be able to look at this in conjunction with band neutrophils, mature/immature neutrophils & possible left-shift & give you an explanation as to what else it could be if it’s not infection – I get a bit boggled with all this myself!)

The Plavix (clopidogrel) dose should be OK as I imagine they’ve given you the correct dose straight away at diagnosis, then checked Max’s clotting time. Just check the dose if your vet if you are not sure or worried. According to
http://www.vetbook.org/wiki/dog/index.php/Immune-mediated_hemolytic_anemia
the clopidogrel dose should be 0.5 – 1.0 mg/kg daily.
You don’t want to overdo it either, as you then get a risk of bleeding. Happy medium.
These clotting problems occur at onset of illness & you just continue the Plavix until there are no more rouleaux, spherocytes etc. seen on the blood smear – they would have been there since the beginning.

Hope I haven’t confused you – this is such a complicated thing to deal with. Get back to me a.s.a.p. if I’ve not explained things properly!

Love Sheena xxxxx