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Azathioprine makes the difference
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Cyclophosphamide plus prednisone or both in combination with azathioprine, what is the best therapeutic choice for dogs with immune-mediated hemolytic anemia (IMHA)? After reviewing 60 dogs with this not uncommon disease with a high mortality rate, the answer is clear!
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Dogs ranged in age from 1 to 13 years, with a mean age of 6.5 years.
The 2 most commonly affected breeds were Cocker Spaniels and Labrador Retrievers.
Fifty-two of the 60 dogs tested (87%) were autoagglutination positive and spherocytes were present in 45 (75%).
Forty-one (89%) of 46 patients tested positive for the presence of immunoglobulin on the red blood cell surface (Coombs assay).
The most common clinical signs at presentation were lethargy, weakness, pale mucous membranes, icterus, hemoglobinuria, and anorexia.
PCV less than 25% was present in 59 (98%) dogs.
At the time of presentation, 35 dogs (58%) had a nonregenerative anemia, whereas 25 patients (42%) had a regenerative response.
Thrombocytopenia was seen in 41 (68%) dogs. Nine of 34 dogs (26%) had a prolonged prothrombin time, 19 of 34 (56%) had a prolonged activated partial thromboplastin clotting time, and 12 of 34 (35%) had abnormal fibrinogen concentrations.
All dogs received prednisone at immunosuppressive doses (2.2-4.4 mg/kg PO as a single or divided dose every 24 hours) and cyclophosphamide as primary therapy.
Forty-one dogs (63%) received cyclophosphamide at 50 mg/m2 q24h for 4 days, whereas 9 dogs (15%) received an initial high dose (200 mg/m2) followed by 3 days of a lower dose (50 mg/m2 q24h).
No statistical difference in survival times was found for either protocol.
Thirteen dogs were treated with azathioprine in addition to cyclophosphamide and prednisone.
The median survival time of dogs that received all 3 drugs was 370 days as compared to 9 days for those dogs that were treated with cyclophosphamide and prednisone alone.
Thirty-one (52%) dogs died from the disease, 13 (22%) dogs were alive, and 15 (25%) dogs were lost to follow-up.
The median length of survival for all dogs was 21 days. Eight dogs that were discharged from the hospital suffered a relapse (PCV < 25%).
Source: Burgess K, Moore A, Rand W, Cotter SM. (2000): Treatment of immune-mediated hemolytic anemia in dogs with cyclophosphamide. In: J Vet Intern Med. 2000 Jul-Aug;14(4):456-62.
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