Thrombocytopenia

[vickyb]

To cut a long story short Sapphy (Seren) is still a poorly girl

She's been having weekly blood tests done to check that her meds, Azathioprine and pred aren't doing too much damage. Her White cell count and platelets have gradually dropped.  After reducing the Azathioprine her white cell count, although low, has stopped dropping but her platelets continue to be worryingly low. Thrombocytopenia is now suspected. The lab are doing further tests on this weeks sample.

Anyone got any experience of this because with her IMPA and given what I've just read I'm now really worried for her
If the tests are conclusive we'll be going back to the hosp with her.

[Lisa]

Has she any symptoms Vicky? I have only dealt with it once a very long time ago and the dog had very clear outwardly visible signs ie nosebleeds and was passing blood in both urine and faeces.

[deborahburt]

I've had no experience of this, but sending lots of for Sapphy.

[vickyb]

May 1, 2013 12:36:06 GMT -5 Lisa said:

Has she any symptoms Vicky? I have only dealt with it once a very long time ago and the dog had very clear outwardly visible signs ie nosebleeds and was passing blood in both urine and faeces.

No she doesn't. She has had a little blood in her poo off and on but the vet thought it was colitis. The lab queried whether she had tummy trouble as although we weren't looking for it they thought she had gut disease from the general results.

It may be that if she does have it we've picked it up early because of how closely she's being monitored.
We've been checking her daily for a while for bruises and red pinpricks on her gums but there's been nothing.

Although she's not responding to her meds as we'd hoped she is happy and content and we're managing to keep her pain under control.
She's such a special little lady who has gone through so much and it's just not fair.

[Ali]

Oh Vicky, sorry to hear that things are not improving for Sapphy.

AI conditions are a bugger to deal with and can take take a long time to stabilise.

What is her current pred/aza dose?
Have you got a note of her dosages of each and their reduction since being diagnosed?
What are her current symptoms - ie. other than the low platelet count are there any outward signs aside from the IMPA symptoms?
Is she still having a gastro protectant (Antepsin or similar)?

As I mentioned to you when we spoke Azathioprine caused all sorts of issues with Murphy - severe bone marrow supression, bruising etc - with the combination of drugs he was going downhill steadily. When the Aza stopped we were able to take stock, reassess (and dismiss the £3.5k specialist advice!) and start again at a slower pace to find a level he could deal with. It took a very long time but we got there, you and Sapphy will do so too, but it could be a while until you get there.

Edited to add another question (re: gastro protectant)

[vickyb]

She had 6 wks of just Aza 50mg daily and although she was more stable on it physically than pred she wasn't making much improvement and during this time her wbc and platelets gradually dropped until her bloods last week went too low and she had a relapse physically too so was changed to 12.5mg pred alternating with the 50mg Aza. She needed a boost of pred initially (25mg thurs and fri) but since the weekend has gradually improved physically and we were hopeful her bloods would show an improvement with the Aza reduced which the wbc has.

She has omeprazole when having the steroids. For pain she has paracetamol am and late afternoon and tramadol at night which seems to be working well for her. Last week she only really wanted to walk on 1 front and 1 back leg but since changing meds she can walk well on all 4 although one of her back legs is a bit wobbly at times.

There are no outward signs of low platelets and we are checking daily for bruising and red spots on her gums but the lab was sufficiently concerned about the current test and the downward pattern to ring my vet and although he's having a few days hol he spoke to them and rang me himself to discuss it and for me to authorise further testing on the sample they have but they strongly suspect thrombocytopenia. The treatment for it is - Aza and steroids.

I want what's best for her but don't want to be rushed into invasive tests which will upset her, especially when she is - this week anyway - doing well physically but then I don't want to miss anything and her have a severe bleed. They are fully aware of greyhounds having different blood chemistry but it's the pattern over the weeks not just the levels that are worrying. She hasn't had any obvious adverse reaction to the aza other than in her bloodwork.

I'm struggling a bit with the fact that aza can cause the platelets to drop but if its caused by her immune system attacking them (which is very likely)  then it's also the treatment - together with the steroids that she's also already on.

[gazer]

Sending the very best of thoughts to Sapphy

Jacqui x

[Lisa]

Lets keep our fingers crossed it isnt. As I say it was years ago and not a Gap dog it was on an old email list I use to use before forums and we were involved as the vets and owners were stumped. This dog became very poorly very quickly and at first they suspected hemolytic anemia but within days the dog had bad visible bruising severe nose bleeds and lots of blood in both urine and faecal content. I always thought it was a very quick acting condition with lots of visible outward signs so really hope that is the case and not what she has x

[julies]

Just sending you hugs Vicky, you must be shattered and beside yourself Hugs for Sapphy too

J xx

[Ali]

May 1, 2013 18:00:53 GMT -5 vickyb said:

I'm struggling a bit with the fact that aza can cause the platelets to drop

It's a difficult one but all of these drugs all have side effects which can counteract or work against the very thing they are supposed to be making better. Obviously I am not a vet and my experiences are based purely on what happened to Murphy and his treatment.

A known side effect of Azathioprine is bone marrow suppression which is why regular bloods need to be taken, especially in it's early stages of use. I think (?) that if Aza is to cause this side effect it would do so within the first couple of months of it's use.

My understanding of what a platelet is that they are bone marrow cells which are released into the blood and help the blood to clot. Therefore, it stands to reason (I think?) that if the bone marrow is being suppressed then a low platelet count would be shown on blood tests. I'm pretty sure it was Murphy's low platelet count that led to the discovery of his bone marrow suppression.

While on Azathioprine Murphy's skin turned black, his breath smelt terribly, he lost even more condition and he was 'depressed'/flat. Once the drug was stopped his skin turned pink again, he perked up and the horrid smell went.

An alternative that you may be offered as another combination drug is cyclosporine - I think I mentioned it when we spoke. We were offered it as an option after the Aza was stopped. It may be something that you might want to research so that if is suggested you are able to make an informed decision (although obviously your vet is best placed to advise and support you).

For us I felt Murphy had been through enough also I didn't want him to have any more 'experiments' so we declined the offer - and the potential side effects were just as risky. We took our chances with Pred only treatment and although progress was painfully slow - I do have my dog back! He's on 5mg pred every other day and has been for around 10-11 months (he was diagnosed in Jan 2009!) and, touch wood, is as fit and healthy as he's ever been. We are very much aware of the effects of long term steriod use but we felt rather that than chosing combination treatments having had such a adverse reaction to the Aza.

I need to dig out Murphy's vet notes to have a proper read back, I have all his vet notes including all the blood work results, unfortunately they are filed in a box under piles of other boxes while the building work is ongoing... I'll see if I can shift a few boxes around at the weekend if I get chance.

Obviously this just my experience Vicky, and every case is different. Your vet will be able to guide you in the right direction for treatement for Sapphy and I hope that you start to make progress soon. It's a very stressful time for all and I remember feeling completely overwhelmed by the weight of it for a very long time.

[vickyb]

Well her results are back but inconclusive. An anti-platelet antibody test result of 30 and over would be a positive result but hers was 27, a bit in no mans land, not quite low enough for a definitive all clear nor quite high enough for a positive Her actual platelet result was 22 down from 25 last week.

So the azathiaprine is stopped and she's having 25mg pred a day, being wrapped in cotton wool and bloods again on tuesday. Apart from the blood results she's been fine - nothing like Murphy, if it wasn't for the bloods you'd thnk there wasn't a problem from the aza at all although I was hoping it would make more of a physical difference than it has.

Apparently as well as the aza affecting the bone marrow and less platelets being produced it can trigger an autoimmune response where the body sees the platelets as invaders and destroys them, including the back up supply in the spleen which is why it sometimes has to be removed in immune mediated thrombocytopenia although it can just happen for no apparent reason as with other autoimmune diseases. That's what the worry is as well as the very low platelet level.

Hopefully by tues her platelet count will improve and we'll now how she is once more on just the steroids and how long her liver can hold out on them too .

I really don't want to progress onto cyclosporine if possible, I have reservations about it too but we'll have to see how she is.
It's so hard having to make decisions about such potentially dangerous drugs but as she was in oct/nov I'd probably have given her anything to help her and do worry about her relapsing to that degree.

She's content so we have to take it a day at a time. Thanks Ali

Any good thoughts for our little girl would be most welcome please.

[loopylou]

Only just spotted this Vicky so sorry Sapphy is still unwell and hope you get her sorted soon. Gentle hugs for Sapphy. Keep your chin up.

[Ali]

May 3, 2013 17:57:23 GMT -5 vickyb said:

Hopefully by tues her platelet count will improve and we'll now how she is once more on just the steroids and how long her liver can hold out on them too

Try not to worry about that just yet, concentrate on getting her stablised on her meds and working slowly towards a maintenance dose. If she responds well she may even be able to go pred free.

I know it's hard - really hard - and you'll be worried sick about her. Little teeny steps in the right direction and tackling one worry at time is the key - and keep a diary. You'll think you are still in the depths one day and read back and realise how far you've come and how much progress Sapphy has made.

Chin up, postive thoughts