High white blood count

[admin]

Hi Jen

Sorry you had to send everything twice. Received the blood tests. I would wait until Maggie’s PCV comes up some more, into normal levels (38 would have been good), before starting a SLOW reduction. She’s still not quite in the normal & my personal opinion if it was my dog would be to wait a little longer. I would prefer to see a completely normal RBC, not borderline, for at least a week, maybe two, before reducing. I see her platelets & neutrophils are still a bit on the high side. This could well be because of the corticosteroids. The platelets are nowhere near the worry level, so no problem. The WBCs are normal now & her monocytes are now normal too, so everything is going in the right direction. Good!!!!!

How is Maggie in herself? Has the diarrhea stopped completely? I suspect the diarrhea was the cause of the tiny drop in PCV since the December test – if it was an infection/parasite, that could also have raised the WBCs, neutrophils & monocytes. Did the vet tell you exactly what it was? It’s a shame the diarrhea has set her back slightly, but these things are sent to try our patience! And my goodness, we all need a lot of patience with this horrible disease. If you want to ask anything else, please don’t hesitate.

Love & cuddles to you & dear Maggie – she’s a sweet girl
Sheena, Worzel & Ollie xxxxx

[Jen]

Thanks Sheena. Her dec test (with the higher PCV of 36) was when I brought her in for diarrhea. Vet determined it was parasite coccidia & it cleared up after few days of treatment. The jan test with lower pcv is after infection cleared. Since early Nov she has held at 35-36 mark & has not risen above. Do you think by continuing on same dosage of meds she could increase pcv levels? It’s difficult bc i feel each time vet suggests a dramatic decrease, I have to confront him & disagree. Originally he wanted to stop cyclo totally in Nov but I argued to reduce by half. Now he wants to stop cyclo & reduce pred by half. So you would not do any reductions at this point? What if I wait few weeks but her PCV still holds at 35-36? Is it possible that it isn’t going to increase?

[admin]

Hi Jen

Oh dear, I wish I had a crystal ball. I have been through this quandry with Linda & I tried to advise her not to reduce the drugs so quickly & to follow the safe protocol – her vet disagreed & Sadie relapsed – it was really horrible. I know she will back me up 100% here – you cannot afford to take risks with this damn disease -please trust me on this. Maggie is so very nearly in range too – very annoying for you Jen. It also means we are “teetering on the brink” of being sure about what to do. I can only give you my personal opinion – I hope maybe someone else will give you theirs too!

Personally, I prefer everyone using the standard drug reduction protocol for IMHA/AIHA of slowly tapering the pred down to nothing or to the absolute minimum first in order to maintain the PCV well within normal ranges. THEN & only then reducing the other immuno-suppressant. Dogs that are treated using this protocol generally do better in my experience & lots of research confirms this.

I am going to try & explain how I understand this treatment protocol in my poor little brain: the pred is a fast acting “stop gap” to urgently suppress the immune system, giving the other longer acting immuno-suppressant a chance to work in the meantime. The pred will hold them at the same level & stop / reduce hemolysis, but will not suppress the immune system enough on it’s own. We know that the longer acting drug doesn’t work overnight & we wait for a stable normal PCV. So, logically when a good PCV has been reached & held for a few weeks, you can reduce the short acting prednisone gradually. Most dogs will be able to stop it altogether because the other drug, in your case the cyclo (and azathioprine???), is now doing the suppressing. Also the pred side effects are horrible at high doses, so getting them off it or as low as possible is the best idea. There are exceptions, for example dogs who relapse – Vally’s Bingo, Linda’s Sadie need to be on a small dose of pred – that’s not the end of the world as long as they are well, happy & the AIHA is under control. I know they would both tell you that these relapses happened because the weaning protocol was not followed properly by their vets. Once you have dealt with the pred, it’s time to reduce the other drug, again gradually, keeping an eye on the stability of the PCV. My specialist who trained at Cornell is completely in agreement with using the recommended protocol. He is good friends with one of the IMHA research vets there, so I trust him. The only reason for going against protocol is for a good clinical reason such as one of the drugs is making the dog very ill.

So my answer is no, I personally wouldn’t reduce anything just yet. I don’t know if Maggie will come up again – you can only get another test done & see what happens. She’s so very, very near the normal range that it’s frustrating for you, I know. If it stays the same & doesn’t improve, my opinion is that the cyclosporine will need to be increased again, but let’s hope that doesn’t happen. Cyclosporine is not a bone marrow suppressant, so you don’t need to worry about that being the problem. Azathioprine CAN suppress the bone marrow – is Maggie still on it? Worzel didn’t have a problem with the aza at all – it worked brilliantly & got him in normal range – but I did notice his PCV kept going up & up even more every time we reduced it (took over a year to reduce it). Sometimes, you can see a little drop in PCV after a pred drop, but it comes back up again – let’s hope that will be the case & in a week or two weeks you WILL be able to do another little pred drop,

I know how difficult it can be to discuss things like this with your vet – you feel awkward & almost argumentative – none of us want to fall out with them – we need them on our side. I did disagree (nicely!) with our local vets at the beginning of Worzel’s illness, I’m afraid, & I’m glad I did, otherwise Worzel wouldn’t be with me now, but it’s horrible to have to do that.

Phew! Hope this helps, Jen.

Love & hugs, Sheena & the very neglected boys xxxx

[Jen]

Yes, she is still on 25 mg aza as well as cyclo & pred. I’ve questioned my vet reducing cyclo before pred in Nov. & he said he usually doesn’t even treat IMHA with cyclo. Funny my vet also trained & taught at Cornell (small world). I do trust him & he is located 10 min from me. & I believe his knowledge & quick diagnosis saved Maggie’s life but I feel he is too aggressive on his reductions. Should I discuss this with him again or just keep giving the same dose & discuss in 2 wks at next CBC? I would rather be conservative! Thanks for your honesty!

[admin]

Hi Jen

Looks like the Cornell “bunch” prefer to use azathioprine then! – their research papers certainly bear that out:

http://www.ncbi.nlm.nih.gov/pubmed/15934255?dopt=Abstract

The T Weinkle is my specialist’s best pal from his training days!

If it were me, I’d just carry on with the same dose for one or two weeks, however often you go for a check-up. That’s my honest opinion as to what I’d do if it were Worzel. I can’t help being a very cautious person – it’s because of living through other people’s bad experiences with them that I am this way.

Let’s cross our fingers, toes, paws (and eyes as Vally would say) that you see an increase next week.

Sheena x

[Jen]

Yes they must! Thanks for the advice. I think I’ll just continue along & discuss it at next appt ( 2 wks). Thanks for the link to aza article as well- interesting stuff!

[Vally]

Jen, yes please do just keep Maggie on the same for another few weeks. The next blood test may solve all issues. Hopefully Maggie’s bloods will have gone up a bit.

Love Vally and Bingo
xxx