Best Hypoallergenic Diet for AIHA – Page 2

Drew

Guest

Dear Patrice,

Thanks again for your helpful, generous reply. We had a vet visit yesterday to address the blood Sophie’s urine. Before our appointment we collected a sample, as you instructed. Luckily we found no visible trace of blood in that sample (or at 3:00 am prior to it). The vet did a Urinalysis based on it, which I have uploaded. It showed negative for LEU, GLU, and BIL. BLD of 50 Ery/ul and KET 15 mgl/dL. UBG normal, and trace of PRO. The vet told us that based on the results, she was treating it as a possible UTI and prescribed an antibiotic. On another matter, Sophie has a cyst (which we removed about 5-6 years ago that has grown back, which has recently ruptured). We were keeping it clean with alcohol and ointment, but when the vet did a needle aspirate, she found an infection so the vet thought the same antibiotic should be able to treat this as well as a possible UTI.

I asked the vet about the high Basophil number that concerned you, and her reply was that it was linked to the bone marrow and attributed it to the prednisone. To answer your question, yes, Sophie has had allergy issues—chronic ear infections. We have never been able to identify the allergen, but our previous vet treated it as a food allergy and put her on a strict no meat diet and only hypoallergenic kibble. Since her AIHA diagnosis, we have been giving her beef (in addition to fish proteins) to increase her protein intake, as well as a wide variety of veges and some fruits to diversify her diet.

Finally, when I asked the vet about the pcv values, she did not think we needed to do another pcv check. As much as I want to know her values, each blood test is expensive, and we are on a budget while trying to prioritize Sophie’s health. We have another appointment for another blood test in 2 weeks. But based on the conversation yesterday, I got the sense that the vet wants to keep Sophie on the full dose until then. I need to have the conversation with the vet about reducing more gradually, as I share your concern about a sudden 50% reduction.

She did tell me what her reduction schedule would look like:

50% reduction (from 10 mg to 5 mg) for 3 weeks (with 2-3 blood tests during this time to see whether stable).
Then, 5 mg every other day for 3 weeks (with 2-3 blood tests during this time)
Then, 2.5 mg every other day for 3 week (same).

Does the remaining schedule also concern you, Patrice?

Finally, you recommend in your post that owners can ask a simple spun pcv during the prednisone reductions. Can you let me know what that is? Is that different from a cbc? Each cbc costs a lot of money (plus a vet visit fee), and with close to 10 planned blood checks over a short span of time, we are worried that the remaining treatment might become prohibitively expensive. Do vets do a simple spun pcv only and charge only for that?

Thank you.
Drew

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Patrice

Keymaster

Hi Drew,
Let’s do the easy stuff first. Of course CBC’s are very expensive. They are not necessary to be done frequently. That’s why the PCV is such a good substitute. You can see a picture of this on this page.
https://www.secondchanceaihadogs.com/AIHA_Terms/pcv-packed-cell-volume

A PCV is packed cell volume. It requires a tiny amount of drawn blood that is put in a small tube and spun. When that’s done you see the “white” stuff (serum and WBC) at the top and the “red” stuff (RBC, Platelets) at the bottom of the tube. They hold that up to a chart on the wall and can tell in an instant what the PCV percentage is. This is actually the more accurate way to determine what you think of as Hematocrit or HCT. In fact all the dogs we see here that are recovering I highly recommend this over the HCT

This little bit of blood can be drawn by a tech, spun and the results known in about 10 min. It shouldn’t cost much at all and that is why I recommended it to you. You don’t need to see the vet. My vet charges me about $15 for the tech visit and the PCV shouldn’t cost more than $15. If they do, they are taking advantage of you. Vally what did you pay in Australia?

So most vets use an automated analyzer to test the blood sample. They take a blood sample and then put that on a slide which goes into the unit. Our dogs here on this forum are very sick and they have a lot of unusual cell types in their blood because of their illness. The analyzer can often make mistakes about what it thinks it is seeing in these dogs. This leads to inaccuracies.

All dogs on prednisone are also very dehydrated so the “make up” of the blood sample tends to have less fluid in it and that means some blood elements seem overly represented on the test. I’ve seen plenty of tests where the dog was dehydrated and it appeared that they had really high platelets. On other tests the report said there was “clotting on the feather edge” and the platelet levels would be artificially way too low! Neither was an accurate reading of the dog’s platelet value.

It’s way too critical to know exactly what that PCV is because medication dosage decisions are being based on that value. That I why I always recommend either the PCV only if the owner has reduced funds or both that an the automated analyzer if they want a more accurate HCT PCV level.

The history of this goes way back to the first world war. The PCV was the only way to evaluate blood. Up until the 1980’s most medical students were taught how to do this as it remains a standard of care.

The main reason for Sophie not to do this rapid decrease is her age and the response I expect is going to happen if she suddenly has half the dose of prednisone removed . We’ve touched on this briefly in the Prednisone Reduction Guidelines link I posted for you.

When we flood the body with prednisone in high doses we are really overloading the dog’s system with what mirrors their own cortisol. The body very carefully monitors this level because it is a critical to our metabolism and many other things like our heart rate, breathing etc. That is why cortisol is related to the “fight or flight” reaction in our body. Cortisol helps us handle stress by activating the appropriate systems to rev up and deal with stress.

When you are almost in a car accident you feel almost woozy and over stimulated to the point that you can’t focus on the details of what just happened.

So the adrenal glands produce cortisol. They do it in response to the many systems I referred to above. When you dose prednisone at very high doses the adrenal glands respond to the flood of cortisol and shut down, not needed. They actually shrink during this period of time. If you suddenly withdraw 50% of the cortisol (prednisone) from the body, the glands are unable to respond to stress properly and can’t provide cortisol, they were asleep and it’s going to take time, in weeks or months, for them to get back to doing this properly.

Dogs live their life on the edge of high stress all the time, everything in their day is either drowsy, sleep or alertness. For a dog the doorbell ringing is the same stimulus as a car accident is to us. They were made this way so they can survive! Dogs haven’t really evolved away from this yet.

So we drop Sophie’s prednisone in half. Let’s say she has this moment of fight or flight, door bell and barking, whatever. He body is going to want to move blood from the extremities to the heart, breathing and heart rate go up very quickly, every system in her body goes into alert mode. But the cortisol isn’t there to do this. She is still going to respond to her instincts to be excited and she is going to collapse. This is an Addisonian Crisis, caused by the administration of prednisone (not a tumor.)

At the minimum she is going to feel terrible for weeks. I’ve reduced prednisone in my own body and I can tell you I felt like dying. It’s not an easy drug to reduce. Many human doctors do reduce like this, 50% right off and then a more gradual rate after. I hated it. But these dogs here are very debilitated, they have been very sick from an illness and the side effects of the drugs. This is a shock to their system.

What if the triggers that started the IMHA are still in her environment or were suppressed in her body all this time and we reduce the prednisone too quickly? She may relapse and we have seen that a number of times, not only in the visitor’s dogs to our website but many of the owners who donated their time to this forum at one time also had this happen. Some of those dogs died from a relapse.

Why did I want to see another PCV right now? I wanted to make sure that this rapid regeneration of red blood cells was not due to some kind of internal bleeding or a relapse of the IMHA destroying red blood cells.

Regeneration is a very good thing to see on blood tests. We love to watch those RBC, HCT and Hemoglobin values rise. But in some cases we see very high regenerative rates because it is a response to continued massive hemolysis (destruction) of red blood cells in circulation.

Here is how I have explained this for years. Imagine you have glass and you want to fill it with water. You go to the tap and fill it up. You set it aside and over a few weeks you notice that some of the water has evaporated. You go to the tap and refill the little bit of water that evaporated. All good. This is how our body normally works, we make blood and we top it off a little bit every day as or old RBC get worn out and are destroyed and new RBC are made.

But lets say there is a small hole in the glass. You fill it up but it leaks a little every day. When you look at it you see it needs more than just topping it off, it’s half empty. That’s a dog with IMHA that is moderate or a dog that has bone marrow failure.

What if there is a huge hole in the bottom. You take the glass to the tap and start to fill it but you can never get it to stay full for more than a few seconds. This is a rapid out of control hemolysis of red blood cells in the body. The bone marrow responds rapidly but you never see the enough red blood cells to replace the ones lost.

So this is an important time right now to make sure that those high values of reticulocytes were actually turning into new RBC and they are indeed hanging around permanently. That’s what I wanted to see with the PCV. If today there was a significant drop, let’s say to 30%, that means there is still hemolysis. The blood in the urine was the key to my thoughts. Many dogs will spill red or orange into their urine when they are in hemolysis. So I was just being cautious for your sake.

Basophils could be high due to the bone marrow but this is quite high. We’ll have to see what is on the next test after the antibiotics are working. What drug did they give you and what was the dose?

No I don’t like the decreases. If this were me I would decrease 25% averaged out over the week. Multiply the dose in milligrams by the number of doses per week. Take 75% of this value. That will be the dose over the week. Now divide by the number of days. Round up to an even number so you are staying on the higher side and also to accommodate how well you can break up the pills to accomplish this, never round down. Monitor her behavior very carefully to make sure she is not experiencing any negative side effects like stumbling, collapsing, not eating, difficulty breathing etc.

At 3 weeks do a PCV (remember this should be a tech visit only and a tiny bit of blood). If it is holding close to 38-40% then begin another reduction. This time you are going to do another 25% of the week’s average dose. You are still going to give it morning and night with the larger dose in the morning if the pills can’t be broken evenly.

At three weeks, another PCV, all normal? Only reduce the weekly amount by about 10%. You are going to attempt to give the dose every other day. If you see any signs of collapse, weakness etc. go back to daily dose every day. You are teaching the adrenal glands to work again, which is like teaching a child how to ride a bike with training wheels. Now you are no longer holding the bike for the kid.

Then another PCV. By now you should know whether she is handling this or not. If she is, then do another 25 % reduction, and give every other day. Or, do a 10% reduction and go to every three days. Always do the math to make sure that this is averaged over the whole week.

Continue at a very low dose, like 2 mg, every 3 days for a few more weeks. Then 1mg every 3 days. Then .5 mg.

If at any point there are other signs that are bothersome, the allergies get worse for instance, ask your vet to prescribe Temaril-P which is a combination of low dose prednisone and trimeprazine. This is well known to treat the itching of allergies very well. So you will be giving a lot less prednisone but also helping reduce the allergies.

Spilling a little protein in the urine needs to be followed carefully. This can be an indication that the kidney’s cannot handle protein well. The kidney diet reference I linked to will be helpful in reducing this occurrence. The kinds of proteins and the amount each day are the critical part of the diet. Mary would agree that most kidney dogs are not in crisis and they should continue to get proteins in their diet. The real thing to monitor is the phosphorous in the diet.
http://www.dogaware.com/health/kidneydiet.html

Mary says this: “If your dog has significant amounts of protein in the urine (urine protein:creatinine ratio above 1.0), then you may need to reduce protein moderately, enough to control the proteinuria, but a really low-protein diet is not considered beneficial, as it can lead to hypoalbuminemia (low albumin levels). It’s best to feed at least 1 gram of protein per pound of body weight daily (the grams of protein must be calculated from a nutritional analysis, it is NOT the same as grams of meat).”

The lab noted on Sophie’s urinalysis to “consider evaluation of the Urine Protein:Creatinine ratio. That is what Mary is referring to. We want to know this value. Once we know that we can feed Sophie properly.
http://www.dogaware.com/health/kidneysamplediet.html

There is also a great group that has been around a long time that has a forum of their own and they can help you with diet.
https://groups.io/g/K9KidneyDiet

Again, I dislike making negative comments about vets to owners and only do so reluctantly when I feel the dog may be at risk. Reducing prednisone very rapidly is like a ride on a very fast roller coaster. You can’t feel sick in the middle of the ride and just get off at that point, you are pretty much stuck until the ride stops. You might be able to finish the ride ok and not feel too bad at the end, but on the other hand you may feel pretty sick.

Are there other vets in your area? I could recommend you see another vet for a second opinion. Some vets hate this, they feel very competitive and resentful if an owner gets another opinion. But the reality is that clinics and vets all have different protocols for how they do things. Prednisone is just one of those protocols. It is a standard drug used for many things in both human and veterinary treatments. The reductions are pretty standard for most things and that is how your vet is approaching this.

On the other hand we have worked with owners for 12 or more years now. I see their tests, we read the details the owner shares with us and we have seen a combination of rapid decreases of prednisone and relapse a number of times. I have always felt that bruising the ego of the vet is less harmful than seeing a dog suddenly decline.

Any other questions? Did I answer everything you needed to know?
my best, Patrice

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Drew

Guest

Dear Patrice,

Thank you again for this thorough and generous reply. It is so very helpful.

Concerning hemolysis, I share your concern about this, and it is a question I posed directly to the vet. I asked whether the blood in urine could the the result of destruction of red blood cells. Her reply was that while this can be the case for humans, it generally does not occur in dogs.

In any event, we will have a follow up visit to the vet to check Sophie’s blood again (and hopefully begin the process of prednisone reduction) in two weeks. I now know that a simple pcv check can be requested to cut down on costs, so will request that moving forward. For the visit in two weeks (or later?), do you think that check of kidney / liver function is warranted? I believe that the cbc the vet has been doing hasn’t tested for kidney / liver function. The last check for this was last August with the prior vet, which showed normal levels.

Concerning your question about the antibiotic, the vet prescribed 7 Simplicef 100 mg tablets, taken over a 2 week period. So far, her cyst seems to be healing okay and we have noticed no blood in her urine or any difficulty urinating.

The link to the information about kidney health is very helpful. We will be sure to monitor the amount of protein we give Sophie.

Finally, thank you for your detailed recommended schedule of the prednisone reduction. I will raise this with the vet and ask for a more gradual reduction and see how the vet responds. I agree with you that Sophie’s health is the priority, and given that she is an older dog, I want to give her the best chance at survival. Concerning other vets in the area, we have already switched vets to this current vet because our prior vet failed to diagnose this condition even when the complete cbc indicated suspected anemia.

Thank goodness that we were able to catch this in time and start her on the prednisone when we did. Had we followed the other vet’s prescription of anti nausea medication and antibiotics, I don’t know where we would be today. But I share your concern about the 50% reduction, so will raise it with her and go from there.

The process of prednisone reduction seems harrowing as you describe. We hope that Sophie responds okay to this. As I wrote last time, Sophie seems to be getting stronger–not the same dog as before the diagnosis, but we see an overall improvement, which has been heartening.

Thank you so much, Patrice. Until next time.

Drew

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Patrice

Keymaster

Drew,
My apologies, I know that blood is not in the urine, but rather I should have indicated that the urine can be DARK because bilirubin is being spilled into the urine and even the stool. This happens when there is damage to a very large number of red blood cells at one single time, the debris overloads the kidneys. The hemoglobin molecules from a large number of destroyed red blood cells are being recycled all at once and the bilirubin comes from that molecule (heme). Iron attaches to the heme and that is what colors the blood red. So any dog in hemolysis will probably have dark reddish urine and a rather muddy stool as the kidneys dispose of the heme in the bilirubin. Normally our urine is a bit yellow and that is the same coloring.

I think your vet has done at least one chemical screen during treatment, I would be surprised if they didn’t. That is where all the important values are that tell us the health of the internal organs and other things like the glucose, electrolytes, albumin and other important values. A full panel is expensive but at least one chem screen should be done to make sure that internally the dog is remaining stable. We call this homeostasis, the dog is managing to control a perfect internal balance despite being ill. A lot of dogs with IMHA and bone marrow failure are actually quite healthy otherwise! There is great hope for these dogs to recover if done correctly.

So the kidneys and liver are important to monitor during this kind of treatment because of the use of prednisone (which must be metabolized by one or the other organ.) The liver enzymes (indicating cellular damage) will go up because of prednisone, there is no getting around this, but once the prednisone is removed the liver is a highly regenerative organ and can recover. My vet is able to break out just a few of these markers from the full chem screen by doing something called a mini chem. Usually includes liver and kidney among a few others. I’ve done this many many times. Less expensive.

Yes you can do the PCV to monitor her at this point. Make sure you request a “technician visit only” to draw the blood and a SPUN PCV. They know how to do this, they are all trained. Always be polite but get what you want done. This is your dog and your money. I would expect any vet treating a dog with this severe of a condition to help the owner by suggesting ways to reduce the costs. Be sure that she is fasted for at least 8-10 hours prior to all blood draws. Lipids in the blood from a recent meal will alter the results and show aberrant readings. On this PCV test, that would show up as a layer of fatty material at the top of the spun tube.

Simplicef is specific for several staph strains and e. coli so is probably covering both the skin and UTI fairly well.

Your experience with the previous vet is shocking. We have seen some clueless vets treating dogs here and it never ceases to amaze me how out of step they are with this condition. That’s the hard part of what we do here, sort out the treatments that are not necessary and point towards the treatments that have become standard and expected.

Again, our goal is to help owners keep their dogs as healthy as possible while they are in treatment and make that treatment as short and successful as possible. In the first 24 hours, the most important diagnosis should be done. There should be a checklist of steps to follow and standardized testing, followed by immediate appropriate treatment. Any dog presenting as yours should be given a CBC immediately and subsequently put on dexamethasone and kept for 24 hours to monitor.

Well, we don’t know, and more specifically I don’t know, how well Sophie can handle this decrease. So our guidance is always from the standpoint that dogs are not equivalent in their health after months of treatment with prednisone. Some dogs may have a very easy time, others won’t. The risk is simple, a dog that has trouble recovering their own cortisol production is going to have a very hard time with the loss of prednisone on a daily basis. Try to compromise with your vet about this. What harm would there be to do a week’s worth of 25% reduction, just to see how she handles it?

With Chance’s treatment I had a very good idea what I was doing. I have a medical background and when he was very sick I bought and studied a veterinary hematology textbook. I worked with Dr. Dodds often by email and studied constantly. My vets were my clinical advisors and answered all of my questions. I have never stopped studying this condition. Luckily now there is more valid research and information on the internet about all these blood conditions. I was treating Chance in 2007-2008. There was nothing on his condition, bone marrow failure. Dr. Dodds was my source for everything on this. I learned so much. In fact it wasn’t until the last 5 years I began to find research and treatment protocols like Dr. Dodds’ on the internet and it confirmed that what I thought had happened to him, from my studying, was actually what DID happen to him.

So vets need to stay on top of this kind of condition. But many clinics may only see this once in a while, and honestly they probably don’t read the information now available. They get irritable with owners who “internet” them constantly. They resent being challenged because they think that the owner is reading nonsense.

You’ve done a great job and I hope you will be seeing some real improvement very soon, as you have mentioned that she seems perkier! That is the sign we look for, despite the test results, is your dog acting like they feel better? If so, then they are probably better!
my best, Patrice

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