Liver Enzymes

Beth

Guest

Hi, my dog Heathcliff was diagnosed with AIHA on 25th January. We have managed to get his anemia under control but he is starting to suffer from the meds. He was originally put on 4mg/kg a day of Prednisone and 1mg/lb a day of Azathioprine (sorry bout the mix of units!) He is a large dog (75lbs) so he was on 140mg a day of prednisone and 70mg of azathioprine. This prednisone amount worried me from the start.

As he had such marked side effects from the start, three weeks ago (2nd Feb) the vet said we can drop it to 120mg to see if this helps. On sunday (15th) the vet found that he had quite severe ascites and we found that his liver enzymes were very high (all three) . On monday i was told to drop the pred to 100mg (about 3mg/kg) and go to every other day for the 70mg of azathioprine. Yesterday (20th) the vet did an ultrasound and all his organs look well apart from his liver which is “huge”. The ascites had reduced significantly. On yesterdays blood check, his PCV was 36 (it was 16 at its lowest). However the vet is very concerned as his liver enzymes are very high; since the start of the week his alkaline phosphatase got a lot worst and his ALT got a “little bit” worst.
The vet has recommended that we stop the azathioprine as she thinks its causing the liver problems and reduce pred to 80mg (just over 2mg/kg) a day. He is also on amazon bought nutramax- Marin at 1 and 1/2 tab a day, Pepcid at 20 mg twice a day, and baby aspirin at 1/4 tab once a day.

I have three worries-
That the pred dose is still too high but I’m worried about tapering too fast, as it seems we have tapered pretty fast already.
That if we stop the azathioprine we wont have a ‘second line of defence’ against the aiha
Whether he is on a good enough quality milk thistle and if the dose is right (each tab has silybin A+B 43mg, zinc 20mg and vitamin E)

The vet is worried about “overt liver failure” and believes that the azathioprine is the one causing the liver issues. I’m less sure, and worry that the pred is such a high dose that it is causing the problems and that we may remove azathioprine when it is needed.

Im unsure of what to do now, i’m so happy we have his anemia under control but so concerned about the med side effects and his liver.

Any useful advice hugely appreciated. I have referred to this forum throughout and it has been such a reassuring and helpful resource.

Many Thanks
Beth

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Keymaster

Hi Elizabeth

I’m sorry to hear about all your troubles no wonder you are worried. Tamara & Brigitte are right – the pred dose is way too high – don’t worry about what’s happened – it’s happened – it’s in the past & we will do our best to get Heathcliff sorted out. The azathioprine is also hard on the liver, but do I feel the prednisone is the culprit at such a high dose.

You need urgent help from a good vet – I would urge you to contact Dr Jean Dodds at Hemopet
https://labordatenbank.com/cake/hemopet/onlineorders/hemopet_add
Please do it today – she is normally very quick at getting back to you & works on a Sunday, but not a Saturday. If you have a blood test, you can scan & attach it to the consultation for her to look at. Tell her exactly what happened with Heathcliff & exactly what drugs/doses he is on. She will get back to you & ask for more information.

The ideal pred dose for Heathcliff at 1mg per pound i.e. 75mg or even 70mg per day divided into 2 doses 12 hours apart. My instinct tells me you will have to reduce it to that level, but I am reluctant to tell you to drop it so quickly in case it makes him ill – these drugs must be dropped slowly in normal circumstances – so Dr Dodds is the best person to advise you on this. Because the dose of pred is so high, Heathcliff’s adrenal glands will be completely suppressed (atrophied) & won’t be producing any cortisol – they need to wake up slowly – they can’t just spring into action. See
https://www.secondchanceaihadogs.com/AIHA_Terms/adrenal-glands/ when you get time.

The azathioprine dosage is right for his weight, so please leave it as it is for now – don’t stop it just yet otherwise he has no secondary long-acting immuno-suppressant. It starts to work after about 10 days or so, so Heathcliff should be suppressed by now. Azathioprine must ALWAYS be given with food to minimise the side effects – that’s very important. Again, carry on with the azathioprine dose until you can contact Dr Jean Dodds. She may want you to change to maybe cyclosporine (atopica) in the circumstances anyway.

See our information on prednisone https://www.secondchanceaihadogs.com/AIHA_Terms/prednisone/
“Prednisone dosage for AIHA/IMHA is normally 1mg per pound (2mg per kilo) per day & should be divided into in 2 equal doses, given 12 hours apart. ”

I know his enzymes look high at the moment & he must have been really uncomfortable, bless him, with the ascites. I promise the Denamarin (containing Milk Thistle) will bring it down, but it will take a bit of time for that to happen. We have seen a few dogs with very high levels, so you’re not alone, and they come down nicely – milk thistle is a wonder supplement for the liver.

My dog Worzel was also on azathioprine & prednisolone & he lost loads of muscle mass too. He looked absolutely terrible, Elizabeth, just skin & bone & it happened very quickly for us as well. Even his head lost muscle (this is called pred head) & his eyes looked sunken & awful. We were very worried about him too, When we started to lower the prednisolone, he started to regain weight, so it will come back, I promise. No wonder you can’t get enough food inside him – prednisone is is catabolic – it eats up muscle mass. For now, try & feed him good quality protein & low fat – as Tamara says, fat can aggravate the pancreas/liver. I’m sure Dr Dodds will send you her liver cleansing diet & will have some dietary ideas to get that weight back on him. Worzel also had high liver enzymes (not as high as Heathcliff) but after only 2 weeks on the milk thistle, they were down into the normal levels.

The sucralfate is also very important as Brigitte said. 1mg tablets are available here in France – I don’t know if you can get them over there though – it normally comes as a liquid, which is a real pain. I sneaked a syringe (minus the needle of course!) between Worzel’s teeth & very slowly squeezed the plunger. He didn’t like it much, be he swallowed it! Thankfully, the pharmacist ordered some tablets for me. That was much easier. Ideally, Heathcliff should have 2 separate 1mg doses a day. Sucralfate must be given well apart from the others medications (see
https://www.secondchanceaihadogs.com/AIHA_Terms/sucralfate/) – 2 hours before/2 hours after. I always found the last thing at night dose eased Worzel’s tummy.
It is really hard juggling all the drugs around – some with food – some without etc etc. If you need help making up a drug chart, our lovely Vally is an expert at doing that for everyone.

So, the most important thing is to contact Dr Dodds immediately. She has helped many of us on here – you will be in the best possible hands. You can manage fine with internet consultations, but I would also have a look around your area for a specialist in internal medicine if you feel the vet your using is not going to be open to expert advice. To put it politely, if in doubt, find another vet. This makes a huge difference to the outcome of this disease – lots of folk on here have had to change vets for various reasons are are very glad they did. I hope Tamara won’t mind me saying she is one of those.

Right – stop worrying too much – it only makes you ill & Heathcliff needs you to be on top form! Dr Dodds will get Heathcliff back on track. I trust her implicitly – you can too. We are all here to support you & do hand holding – that’s very important to all of us when our dogs are so sick. Any questions you think of, just ask.

Hugs from us all
Sheena, Worzel & Ollie xxxxx

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