Reducing meds?

[Jen]

Hi, I’m hoping you all can give me some advice regarding reducing medications. Maggie’s vet called and would like to start reducing her medications. I know everyone here says to make sure you reduce medications slow… She is on 20mg pred, 50mg aziathioprine, and 100 mg cyclosproine as well as a stomach protector. Her vet would like to stop the 100mg of cyclosporine all together. Are any of your babies taking cyclosporine? Or is that necessarily a typical long term treatment for AIHA. Prior to her diagnosis she was taking 50mg of cyclo for skin allergies. I just was hoping to get some reassurance that this is not too dramatic of a reduction.
Also, I am still giving her 1/2 tablet of baby aspirin daily and the vet I can stop. Any thoughts.
Thank you for any advice.
Hope everyone and their babies are doing well!
Jen & Maggie

[admin]

Hi Jen. Oh, this is a scary ordeal. But you and Maggie can do it! What was her latest PCV?

I know others will give better advice on this than me, but I have to say – I am VERY against totally stopping ANY immune suppressant ALL AT ONCE – THAT’s an AIHA 101 NO-NO. All the suppressants need to be done slowly and orderly. Trust me, I’ve done it now three times! Sadie – good ol gal – has rallied every time, thank goodness. But I know first hand, SLOW and LOW.

I did it all backwards – and intermittently – all intentional, with Sadie due to some complications from very long term dosing. Typically, I think most here start to wean the prednisone and then the cyclosporine. And I am not sure where the azathioprine weaning would come into play, as it seems she is on three (3) immune suppressants? Have you been giving anything for the liver with these three immune suppressants? Denamarin? I sure hope so. I would definitely NOT stop the stomach protector until you get VERY low on the immune suppressants. Nor would NOT stop the aspirin.

My general rule is to lower one suppressant at a time. Each should be lowered from 15 or 20 or 25% at a time. I lower every 30 days, but like I said, due to her relapse, I tended to be super paranoid and go overboard, except for this time.

So, say with Sadie and this last relapse (not quite a month ago, she was put on 20mg prednisone (only). That was it – no other immune suppressants. At relapse her PCV was 23. She rallies fast and last week was up to 42. We decided to start the wean after only 19 days – to 15mg (which was tough for me to do, plus it’s 25%!). She will be on that for at least three weeks this time. Sadie has been on immune suppressants since 2012 – we need to get her to her maintenance dose – most likely 5mg, for life (it’s okay – I’ll take that). She relapsed after getting her down to 2.5mg for over a month – darn. I tell you this, because this wean, right now, is her third wean and is breaking all my own past rules. We do another PCV tomorrow morning – we will then see.

I know others will post – they really are much more on this than me. But I know – they will all agree – SLOW and LOW. You can do this. My vet was wonderful but he weaned Sadie too fast. Everyone here tried to (ever so nicely) tell me NOT to wean her so fast, but I was caught up in that, “but he’s my vet and he told me to” – he must be right. Nope. Wrong, not right. She totally relapsed. And we were at square one. But she’s a fighter and still here. :)

You hang in there with your Maggie. You both can do this – just slowly.

Love and huge hugs, Linda and Sadie baby

[Vally]

Jen, Bingo still takes 25mg of cyclosporine every second day, along with 1.25mg of prednisone daily (he weighs 7.5kg – about 16.5 pounds). As we’re not reducing his prednisone any further, just today, we decided we’d lower his cyclosporine, however, we’re going from 25mg every 2nd day to every 3rd day, so I’m with Linda, I don’t like the idea of stopping it abruptly.

Now perhaps because Maggie is also on 2 other immunosuppresants, perhaps that’s why her vet feels it’s safe to stop it abruptly, but with skin issues too, um I’m a bit wary of this. Sorry I know you don’t want to hear this.

If it were me, I’d suggest I’d prefer to do a reduction rather than stopping abruptly, just to be on the safe side.

Love Vally & Bingo.

[admin]

Hiya Jen

Wonderful to hear Maggie is doing well & you can start thinking about reductions. As you know, I am not a vet, but have read as much as I possibly can & have the experience of lots of people going through the same predicament as you are in now. Here is my opinion. I am totally against stopping the cyclo all at once. I am also of the opinion that you should be reducing the prednisolone slowly FIRST until she either stops it altogether (most dogs can) or you find the lowest possible dose to keep her stable (a small number of dogs need a small amount of pred forever – it’s no big deal). Ideally, 25%-30% reduction per month is nice & slow & less risky. If Maggie is suffering from pred side effects very badly, there may be a clinical reason your vet would reduce it faster, BUT you need to be aware of the risk of a relapse & a possible Addisonian crisis if the reduction is too fast for the adrenal glands to re-start (they “go to sleep” during pred treatment & can only start working again slowly).

Then you can start reducing the other drugs. This is the most usual tapering method – stop the pred, then gradually reduce the other drugs. This was what we did with Worzel – got him off the pred as it was eating him alive, then reduced the azathioprine very slowly by dropping one tablet a week every month (it took a year in fact) until he took 1 x 50mg per week – and he still takes that one tablet as an insurance policy. I have no personal experience with cyclosporine, but stopping any immuno-suppressant completely without tapering it down is asking for trouble & I would refuse to do it personally because there are many people on here whose dogs take it & we all know slow reductions prevent problems. Did your vet give any reason for this idea? I believe caution & patience is vital with this disease to prevent relapses.

I hope this helps – I beg you to be very careful – we only want the best possible recovery for Maggie & do not wish to scare you, just give you our experiences & advice.

Sending love & cuddles to you & dear Maggie
Sheena & the boys xxxxx

[admin]

Jen
Sorry – should have said I agree with Linda – I would not stop the aspirin or the tummy protection either. Your other problem is also that you don’t know which drug actually worked on the IMHA – was it the azathioprine & cyclosporine? Or both as a combination? We don’t know, therefore proceed with caution on the tapering to avoid a relapse. I fully appreciate we all hate the side effects of these nasty drugs, but they are life-savers.
Sheena x

[Jen]

Thank you for responding. When he told me about stopping it altogether I asked him if he thought it might be too dramatic & cause a relapse. He said he treats others dogs with aiha without using cyclosporine at all so he thought it would be safer. I had a bad feeling the moment he said it. Her hematocrit was 38 last week. She is on Sam E, milk thistle, melatonin, Pepcid ac, & aspirin as well.
I can’t help but think he’ll be insulted by me questioning his choice in the stopping the med. All of you have been through it so I trust what you say & will question him.

Many thanks
Jen & Maggie

[Vally]

Jen say something like, for your sanity you feel you could cope better by reducing it slowly. Thats the case with me. My guy knows I’m terrified of reductions.

Love Vally and Bingo

[admin]

Jen, I know this is very difficult & you don’t want to have an argument with the vet if at all possible – we need them badly to support us through this. BUT Maggie is YOUR dog, not his, & you need to be strong for her. This is awkward & I know many others have faced this exact problem. Some have even had to change vets & sometimes this is the only sensible option. I hope you can work something out though. If in any doubt, I would contact Dr Dodds – we all admire & respect her & she will help you. https://www.secondchanceaihadogs.com/hemopetresources/

Is this the same vet that you had at the beginning? Is he aware that you now have a lot more knowledge behind you? Exactly how many other dogs with AIHA has he treated/is he treating? My specialist had only treated 3 since leaving Cornell Uni & it is a big practice (obviously his previous experience was gained as he had come across many dogs during his internship training at Cornell Uni), so …. you know what I am saying. So tricky. If a vet told me to stop the cyclo, I would want a very good clinical reason why. If you feel brave, maybe ask politely if he was 100% sure that Maggie would not relapse & maybe even politely ask for that in writing! I like Vally’s idea about saying how worried you are as a ruse for doing things differently. That could work well.

I have to tell you what I think because it is worrying me because I have seen too many relapses & I don’t want you to experience what Linda went through – I “lived” through that with her & Sadie – it was horrible for Linda – & I don’t want that to happen to Maggie. She’s right – sometimes we are too polite – this is serious stuff – a very serious life threatening disease that you can’t afford to take chances with. Yes- you could be lucky & Maggie will be fine – but what if she isn’t? I personally wouldn’t take the risk of doing something so drastic – that is my opinion. I know you will think of a way to get your point across somehow. Sorry to rant on, but it is important because we care about each other on here. Anything we can help with, just ask.
Love Sheena xxxxx