ITP in dogs can be a scary diagnosis but it doesn’t have to keep your dog from living a great life. Take it from Dr. Laura Garlow, veterinarian and mom to Fletcher, a Goldendoodle who lived with ITP for nine years. On the invitation of integrative veterinarian Dr. Julie Buzby, Dr. Garlow takes a comprehensive look at ITP in dogs and shares her experience walking this path with Fletcher.
I think that everyone’s first dog as a “grown-up” holds an extra special place in their heart. That was the case for me and Fletcher. I like to affectionately call Fletcher the “best bad dog” in the world. No other dog will ever be able to fill the Goldendoodle-sized hole he left in my heart when he passed away a little over a year ago at the respectable age of 11. He had a long happy life, nine years of which he lived with immune-mediated thrombocytopenia, but it still never feels like long enough.
My now-husband (who was my fiancée at the time) and I picked Fletcher up as a rambunctious ball of fluff the summer before I started veterinary school. I wanted to make sure I did everything right. So I spent that summer reading all the puppy training manuals I could and hiding everything chewable in our little apartment.
Fast forward a couple of years and Fletcher had turned into a pretty great dog. Maybe the puppy training manuals I poured over so carefully had worked. Or maybe he was just destined to have a wonderful temperament. Regardless, he was a good boy and he brought us so much joy.
Tiny signs of an issue with blood clotting
My husband and I got married during the summer between my second and third year of veterinary school. While on our honeymoon, we boarded Fletcher at a doggy daycare that he loved. He had a blast playing with his doggy friends but had gotten a little scruffy. So when we got home, I gave him a bath, dried him off, and brushed him out. He was his normal self at that point. But just a couple of hours later, I noticed that the insides of both of his ears were covered with tiny pin-prick red dots where I had brushed him.
While I was only halfway through my veterinary education, I knew enough to know that this was not normal. With a bad feeling in the pit of my stomach, I quickly texted a picture to a close friend and mentor. He confirmed my fear that the tiny pin pricks looked like petechia, or very small bruises. Then he gently reminded me that petechia are evidence of an issue with blood clotting. This meant we needed to have some lab work performed ASAP to try to pinpoint the problem.
Since Fletcher was otherwise feeling well with no other evidence of bleeding or bruising, we decided that it was okay for me to wait to take him into the clinic until first thing the following morning. I didn’t sleep a wink that night.
A diagnosis of ITP, immune mediated thrombocytopenia
We went into the clinic the next day. A couple of blood tests later and just like that, Fletcher had been diagnosed with immune mediated thrombocytopenia, or ITP.
This diagnosis had a profound impact on our family, and on my career. I developed a special interest in internal medicine and immune-mediated diseases. This interest led me to complete an intensive one-year internship at a specialty and emergency veterinary hospital after graduation. I found that I enjoyed the challenge of complicated medical cases, and I especially enjoyed helping pet parents understand and navigate the challenging situation of having a hospitalized pet.
After my internship, I spent many years at the same specialty hospital caring for sick hospitalized patients. In that time, I treated many wonderful dogs with immune-mediated thrombocytopenia. Through the years, I have learned so much about this condition, both from our experience with Fletcher, and from my experience caring for my patients. I want to share some of my knowledge with you.
If your beloved dog has been diagnosed with ITP, I hope you finish this article feeling empowered with the knowledge you need to face this challenge head-on.
What is ITP in dogs?
Immune mediated thrombocytopenia (ITP) is one of several autoimmune diseases in dogs. In ITP, the dog’s own immune system attacks and destroys his or her platelets. As a result, the dog has thrombocytopenia, which is the fancy medical term for a low platelet count.
Platelets 101
Platelets are tiny cell fragments within the blood. They are made in the bone marrow and are vital to blood clotting. You may think about platelets helping stop bleeding from a large cut or wound, but platelets aren’t just there for the primetime trauma. They also prevent life-threatening bleeding from normal daily microscopic wear and tear to blood vessels. When these tiny tears occur, platelets clump together at the site of the damage to form a blood clot. This stops any bleeding before you would even be able to notice there was an issue.
Normal platelet counts vary depending on the laboratory equipment being used to measure their levels. Generally speaking, a normal platelet count is anywhere from about 180,000 to 500,000 platelets per microliter of blood. Most of the time, there are no signs of ITP until the platelet count dips below about 40,000 platelets per microliter of blood. At that point, the risk of spontaneous bleeding sets in.
Occasionally, dogs are diagnosed with ITP due to a moderately low platelet count found by accident on routine yearly bloodwork. However, it is much more common for dog parents to have no idea there is a problem until the platelet count is less than 10,000 platelets per microliter and their beloved companion starts showing obvious signs of bleeding.
What are the symptoms of ITP?
The clinical signs of ITP can be broken into three main categories:
1. Direct signs of bleeding or bruising
- Small pinpoint bruises on the skin or mucous membranes (i.e. petechia)
- Larger bruises on the skin or mucous membranes (i.e. ecchymosis)
- Blood in the urine (i.e. hematuria)
- Dark, black, or tarry stool (i.e. melena)
- Fresh red blood in the stool (i.e. hematochezia)
- Blood in vomit that can appear like coffee grounds ( i.e. hematemesis)
- Nose bleeds in dogs (i.e. epistaxis)
- Bleeding into the whites of the eyes (i.e. scleral hemorrhage)
2. Signs related to anemia in dogs (i.e. low red blood cell count) from losing too much blood
- Pale or white gums
- A lethargic dog
- Decreased appetite
- Exercise intolerance
- Rapid heart rate
- A dog who is breathing fast
- Collapse
3. Signs related to the body system where bleeding has occurred
- Blindness from bleeding into the back of the eye (retinal hemorrhage)
- Dog seizures or other neurologic signs from bleeding in the brain
- Difficulty breathing from bleeding into the lungs
If you notice any of these signs, please make an appointment with your vet immediately. In some cases, severely affected dogs may need an emergency vet visit .
How does the vet reach an ITP diagnosis in dogs?
At the appointment, your veterinarian can check your dog’s number of platelets on the in-house laboratory equipment as part of a complete blood count (CBC). Since low platelets are the primary characteristic of ITP, a platelet count is the diagnostic tool of choice.
The CBC will also allow your veterinarian to check your dog’s red cell count. This is important as anemia can be present due to bleeding from ITP. Or sometimes ITP is combined with immune-mediated hemolytic anemia (IMHA in dogs). Evan’s Syndrome is the name for ITP and IMHA in dogs.
Occasionally platelets can clump together and read as falsely low with in-house machines. This means that in most cases, your veterinarian will want to confirm the low platelet count by looking at a blood smear underneath a microscope.
The vet will also take into consideration your dog’s age, gender, and breed when diagnosing ITP. Any dog can have immune-mediated thrombocytopenia, but like most conditions there are some dogs who might be more predisposed. Many auto-immune conditions are more common in females, and ITP follows that trend too. Middle-aged dogs are the age group most likely to have ITP. Some breeds have a higher risk as well. These include Poodles, Cocker Spaniels, and Old English Sheepdogs.
Once the vet has determined your dog has ITP, he or she will start looking for the underlying cause, if there is one.
What causes ITP in dogs?
When veterinarians think about ITP, they break it into two classifications—primary and secondary. Primary ITP (i.e. idiopathic ITP) is a diagnosis of exclusion. This means the vet will use additional diagnostic testing to rule out the presence of a trigger. If the vet doesn’t find a clear cause, he or she will categorize it as primary ITP.
Secondary ITP occurs when another medical condition triggers the immune system to run amok within the body, attacking its own cells. Common triggers of secondary ITP include:
Infections
Almost any infection can over-stimulate the immune system and trigger autoimmune disease. However, there are some infections where this is a much more common occurrence than others. Fleas and ticks spread many, but not all, of these infections.
Some of the more common infectious triggers of ITP include:
- Tick-borne disease in dogs such as Ehrlichia, Rocky Mountain Spotted Fever, or Babesia
- Bartonella
- Mycoplasma
- Leishmania
- Leptospirosis
- Heartworm disease in dogs
- Systemic fungal infections
Drugs or vaccines
- Sulfa drugs
- Cephalosporins
Note: While vaccines were once thought to be a common trigger for immune-mediated diseases like ITP, more recent studies have not supported this link. In general, vaccines are safe and do a great job of protecting your pet from preventable illness. If you are wondering which dog vaccines are absolutely necessary, I recommend having an open conversation about your concerns with your veterinarian.
Cancers
- Lymphoma in dogs
- Leukemia
- Multiple Myeloma
- Histiocytic Sarcoma
- Hemangiosarcoma in dogs
How do you find the underlying cause?
To look for these triggers, your veterinarian will study your pup’s medication and vaccine history, ask you questions about preventative medications and lifestyle, and run additional diagnostic tests.
Your vet may perform a more limited in-house test for some common tick-borne infections. Alternatively, more comprehensive tick panels are available through outside veterinary diagnostic laboratories. In some cases the vet may decide to start a course of the antibiotic doxycycline while awaiting these results because doxycycline is effective against many tick-borne diseases.
To look for any underlying evidence of cancer, your veterinarian will likely recommend full lab work. He or she may also recommend chest and abdominal radiographs or even an abdominal ultrasound.
Fletcher’s ITP trigger
In Fletcher’s case, he had not been on any recent medications and we were diligent about giving him his flea, tick, and heartworm preventative medications. His chest radiographs were normal. Since I had access to internal medicine specialists at my veterinary school, we also performed an ultrasound and a more comprehensive infectious disease panel a few days later. Thankfully, Fletcher’s ultrasound did not show any evidence of cancer.
When the infectious disease panel came back, we were surprised to discover that Fletcher was positive for Bartonella, an infection that is spread via fleas and can sometimes trigger ITP. We treated Fletcher’s Bartonella infection with a course of antibiotics and crossed our fingers.
Many times, if you treat the underlying trigger, the ITP can resolve. However, this was unfortunately not the case for Fletcher. His ITP did not go away, but with the help of daily medications, he managed to have a wonderful life.
What is the treatment for ITP?
After reaching a diagnosis of ITP, the veterinarian will propose a treatment plan. It may involve:
Immunosuppressive medications
An out-of-control immune system is the root problem with ITP. So you would be correct if you guessed that medications to suppress the immune system are the mainstay of treatment. Steroids like prednisone for dogs are almost always part of the arsenal. However, the vet may also add on other secondary immunosuppressive medications like cyclosporine, mycophenolate, or azathioprine.
Vincristine
If your furry friend ends up needing to be hospitalized for ITP, your veterinarian may talk to you about a medication called vincristine. This is an injectable chemotherapy medication. Since it is given at a lower dose for dogs with ITP, side effects are rare. Vincristine functions to push any leftover tiny platelet fragments out of the bone marrow and into circulation. Studies have shown that dogs who receive vincristine have slightly shorter hospital stays due to a more rapid increase in their platelet count.
IVIG
Intravenous Immunoglobulin (IVIG) is a more intensive treatment option that veterinarians usually reach for in severe cases or if a patient is not responding to more standard therapy. It is a human product and can be quite expensive, making it cost prohibitive for many pet parents.
IVIG essentially works by neutralizing the immune system cells by clogging up the site where they would bind to the platelets they were planning to inappropriately destroy. It is an injectable medication that must be given in the hospital as an infusion. IVIG can be a good option for some situations, and is generally well-tolerated. However, it is not a common day-to-day medication in the arsenal against ITP.
If you are interested in learning more about vincristine and IVIG, a study published in the Journal of Veterinary Internal Medicine compared these two options in dogs with ITP.
Blood products
Some dogs with ITP experience significant blood loss since they cannot mount an effective clotting response. If dogs lose enough blood that they are experiencing clinical signs from their anemia, they may need a blood transfusion. Packed red blood cell transfusions are the most common type of blood transfusions performed in veterinary medicine. These transfusions don’t provide any platelets or stop the bleeding, but they do stabilize the patient to buy more time for the medications to stop platelet destruction.
In some cases, veterinarians may reach for a whole blood transfusion to help with anemia and ongoing life-threatening bleeding. Whole blood contains both red blood cells and platelets, but unfortunately the platelets in the transfusion last for an incredibly short time inside the body. They may very temporarily help with severe bleeding, but this effect is short-lived. Unfortunately, a whole blood transfusion will not lead to an increase in platelet count.
Since ITP destroys platelets, it would seem like giving the dog more platelets would be a good treatment option. However, while platelet transfusions are relatively common in human medicine, they aren’t that useful in dogs with ITP. Two issues are at play in this situation. The first is that canine platelet products have somewhat limited availability. The second and more significant issue is that the platelets, once transfused, will be destroyed within hours by the same abnormal immune response that is destroying the dog’s own platelets.
Other supportive care
If your beloved pup is diagnosed with ITP, your veterinarian may add in other supportive medications to help treat specific symptoms. These may include:
- Antacids or stomach coating medications if your dog is experiencing gastrointestinal bleeding.
- Antinausea medications if your dog is nauseous.
- Appetite stimulants for dogs if your dog is not eating.
Your veterinarian will work closely with you to tailor the medication and treatment plan to your furry family member’s specific situation.
What is the prognosis and survival rate for dogs with ITP?
Using the treatment options we just discussed, the short-term prognosis for ITP Is good. The overall survival rate is roughly 80 to 85%. Unfortunately, though, this does mean that 15 to 20% of dogs pass away or are euthanized due to ITP.
There are a couple of factors that have been linked to a lower survival rate for some dogs with ITP. These include bleeding from the GI tract and an elevation in a blood marker known as BUN. If your pup falls into one of these categories, instead of losing hope, I recommend specifically talking to your veterinarian about your worries and discussing ways to tailor your dog’s treatment to his or her specific clinical situation.
The ups and downs of ITP treatment
One of the harder things to counsel clients on during treatment for ITP is the very normal, but understandably anxiety-inducing waiting game. It can take anywhere from four to seven days on average for immunosuppressive medications to kick in. During that time, we often check the platelet count and red cell count on a daily basis.
It can be very disheartening for dog parents to see that platelet count go from 8,000 to 5,000 to 5,000 again, especially if their dog is showing signs of bleeding. However, it is important to understand that just because a dog hasn’t responded over the first few days, doesn’t mean they still don’t have a good chance of responding positively to their medications.
Indications of improvement
You can breathe a sigh of relief when your dog’s platelet count increases above about 40,000 platelets per microliter. This is generally when your veterinarian will consider your dog to be out of the woods. At this level, life-threatening spontaneous bleeding is much less likely. Even so, you will want to treat your dog as if he or she is quite fragile until the platelet count increases back into the normal range.
This means no running or jumping or boisterous play. I even tend to recommend soft or canned food to decrease the risk of bleeding from the gums while waiting for the platelet count to normalize.
Happily, once the platelet count begins to rise, it normally continues to do so very quickly. Your veterinarian will likely want to monitor the platelet count every several days until it is normal. Once the platelet count has been in the normal range for three to four weeks, then the first step is to gradually reduce the dose of the steroid medication (often prednisone).
The vet typically decreases the dose by about 25% every three to four weeks while continuing to monitor to ensure the platelet count does not start to drop back down. If a secondary immunosuppressive agent was part of the treatment regimen, the vet will decide whether or not to stop or wean that medication once he or she is able to get the dog off steroids.
Medication side effects
Vets aim to taper the steroid dose first because while steroids are potent and effective medications to suppress the immune system, they do come with a number of side effects. Being able to use lower doses of steroids can be one of the advantages of adding in a secondary immunosuppressive medication.
All dogs are susceptible to experiencing steroid side effects, but large and giant breed dogs tend to be most sensitive. Some of the side effects you might see with chronic, high-dose steroid administration include:
- Increased thirst in dogs and increased urination
- Increased panting
- Lethargy or listlessness
- Weight gain, especially for small to medium-sized dogs
- Weight loss and significant loss of muscle mass, especially for medium to larger breed dogs
- Pot-bellied dog appearance
- Increased appetite
- Increased risk of other infections (skin infections, UTIs in dogs, etc.)
- Thinning of the skin
- A thin or dull haircoat
- Insulin resistance, which may increase the chances of diabetes mellitus or cause issues in an already diabetic dog
- Iatrogenic Cushing’s disease in dogs
If you think your dog’s steroid side effects are becoming problematic, speak to your veterinarian. He or she may be able to adjust your dog’s medications to reduce or eliminate some of the side effects.
What to expect long-term
Because of these side effects, vets always hope that we will be able to wean our ITP patients off all of their medications. That is possible in many cases. However, approximately one-third of dogs will have a relapse of their ITP either during their medication tapering or at a later date.
Sometimes it can be harder to get these dogs back into remission, but often they do still respond well to immunosuppressive medications. In some cases, dogs end up on life-long immunosuppressive medications to keep their ITP at bay. The vet will always try to get them on the lowest doses of medications that both control their disease and minimize their side effects.
Fletcher’s long and happy life with ITP
I can’t end this article without telling you what happened to Fletcher. He responded well to his medications and went into remission quickly. Happily, he never ended up needing a stay in the hospital or any blood transfusions.
A couple of months after weaning off his medications, a routine recheck revealed a significantly decreased platelet count. This indicated a relapse, which of course we felt disappointed about. He responded well again but his platelets dropped once more as we got him on the lowest doses of medications. This meant that he fell into the camp of dogs who need lifelong immunosuppressive medications to keep their disease at bay.
We bought a pill organizer, and we were diligent about giving his medications every day and keeping up with his routine rechecks. He experienced some side effects of the long-term steroid use including having to pee more often and losing a lot of his muscle mass. Luckily, at this point I was working at a specialty hospital. The internal medicine specialists were great about giving me lots of advice on his care.
We switched up his medication cocktail and found the right combination of medications that kept him in remission but also minimized his side effects. He lived a very happy life on those medications for more than six years.
Fletcher’s legacy lives on
Fletcher’s happy-go-lucky nature was both a blessing and a curse because by the time he started to act sick from cancer (unrelated to his ITP), it was already in his liver, spleen, and bones. We kept him as comfortable as we could and fed him lots of tasty, previously off-limits foods. Then we let him go when he told us it was time.
We still miss him very much, but we have so many wonderful memories with him. I am grateful for all the lessons he taught me, both about navigating a diagnosis of ITP and about how to empathize with dog parents when they are dealing with a complicated medical condition in their beloved companions. I hope that if you are facing a diagnosis of immune-mediated thrombocytopenia with your beloved dog, this article and Fletcher’s story give you the knowledge and the hope you need to make it through to the other side.
Has your dog been diagnosed with ITP?
What words of advice do you have for other dog parents who find themselves in a similar situation?
Hello Dr.Bubzy !
Fletcher’s story was an inspiring and motivating read in a time of distress. My 2 and a half year golden retriever, Fudge, has been diagnosed with anaplasma. The first most noticeable symptoms were fever, vomiting and eventually black stool. His platelets dropped to 134 and so did his rbc to 4.34. In the beginning he refused to eat anything and even if he did he would throw up, he had a spike in his fluid intake. Our vet decided to put him on iv for 2 days and he was put on doxy. He’s been on doxy for 4 days now and he hadn’t thrown up after the iv until tonight. His BUN levels are normal but there is a slight increase in his bilirubin and SGOT levels. Our vet has prescribed him ethamsylate to stop the internal bleeding as well as sucralfate for stomach coating. He is usually a highly energetic dog but has been lethargic as of late.
i have noticed a few positive changes ever since he started medications :
1. he had a very rapid breathing rate before but it has gradually become normal.
2. a few days back when we were waiting for his results, we noticed he had very pale gums but that too has gotten better
Besides this, his appetite hasn’t fully restored which i would like to guess is because of the medications? Regardless, i would love to hear your opinion especially if possible, i’d love it if you can tell the severity of his situation. I cannot afford to lose him
Hi Shanaya,
I am so sorry Fudge is dealing with the effects of this terrible disease. Unfortunately, without examining him myself, it is hard to make specific conclusions about his condition. From what you describe, it does sound like there has been some improvement. I am hopeful that the doxycycline will continue to work and give your boy a chance to stabilize. Wishing him all the best and praying for a full recovery.
This is a really great piece, thank you. My dog was hospitalized three years ago with ITP and received blood transfusions, chemo, the works. Now at 13 his teeth are rotting and infecting his gums (from a lifetime violent refusal to let me brush his teeth!) and his vet says the teeth need to be removed, but obviously the anesthesia and bleeding from teeth removal are a huge risk for an ITP relapse. I’m trying to weigh whether the high risk procedure is worth it to make him more comfortable, or if letting the teeth rot is a better fate than a serious relapse. Would amping him up on his previous steroid medication better prepare him for a surgery like this? Or should I consider the whole thing too big of a risk?
Dear Stephanie,
I am sorry you are facing this difficult decision for your senior pup. I understand why you are conflicted about how to proceed and wish I had some great advice. Unfortunately, without playing a personal role in your dog’s medical care, it is hard to offer specific recommendations. If the ITP is stable and platelet numbers look good, I would probably try the dental procedure for my own pup. While a relapse is a possibility, dental pain is a real concern, and I would not want to force anyone to live with chronic pain if there was a way to prevent it. Here is an article with more information: Senior Dog Tooth Extraction: What to Expect
I am not sure there is truly a right or wrong way to proceed in this situation. No matter what you decide, your vet should be able to offer pain medications and help with comfort care. Praying for clarity and wishing you both nothing but the best.
Hi Dr Buzby!
i know it has been quite a while since i last wrote on here about Mowgli.I had a lot going on and for some reason typing on here seems to have a bug from my phone.Mowgli is still doing good! I have him checked every 4 weeks and his platelets remain around 550.I am still supplementing him.Last August i had a bit of a scare when they made an ultrasound of him as they found an incidentilome in his left adrenal gland.I had him tested for Cushing and a pheochrocytome but he tested negative for both.Two weeks ago i had another ultrasound made and luckily no growth was detected in the adrenal gland and spleen! By the way,have you seen the new protocol in how to treat ITP? My veterinarian sent it to me and told me that after she discussed Mowgli at the convention they have a new consensus statement on AVCIM where Romiplostime is now mentioned!Meanwhile 3 other people saw my messages on here and reached out to me with questions😃And this all thanks to your great platform!Again,sorry that it took me a while to get back at you but we are still alive and kicking!
Bye for now,Greets,Chomissa
Hi Chomissa,
It is so good to hear from you! I was thinking about you and actually mentioned you in a reply to another reader just the other day! I am glad Mowgli is doing so well. I needed that good news today. ♥ I haven’t seen the updated ITP protocol yet. Do you have a link to it by any chance? I am still amazed at how Mowgli’s case has helped propel veterinary medicine forward in this area. I feel like I know a celebrity. 🙂 Thank you for playing an active role in offering guidance to our readers facing this difficult disease in their own pups. As always, wishing my best to you and your boy. Keep up the good work!
Hi Dr Buzby,
The title is to be found on the veterinary journal of medicine and is called ACVIM consensus statement on the treatment of immune
thrombocytopenia in dogs and cats.
The date of the article is mation on the pathophysiology, diagnosis, and treatment of clinically important animal diseases. The ACVIM Board of Regents oversees selection
of relevant topics, identification of panel members with the expertise to draft the statements, and other aspects of assuring the integrity of the
process. The statements are derived from evidence-based medicine whenever possible and the panel offers interpretive comments when such
evidence is inadequate or contradictory. A draft is prepared by the panel, followed by solicitation of input by the ACVIM membership which may
be incorporated into the statement. It is then submitted to the Journal of Veterinary Internal Medicine, where it is edited prior to publication. The
authors are solely responsible for the content of the statements.
ACVIM consensus statement on the treatment of immune
thrombocytopenia in dogs and cats
Dana N. LeVine1
| Robert Goggs2
| Barbara Kohn 3 | Andrew J. Mackin4
|
Linda Kidd5
| Oliver A. Garden6
| Marjory B. Brooks7
|
Erin R. B. Eldermire8 | Anthony Abrams-Ogg9
| Elizabeth H. Appleman10
|
Todd M. Archer 11
| Domenico Bianco12 | Shauna L. Blois9
|
Benjamin M. Brainard13
| Mary Beth Callan14
| Claire L. Fellman15
|
Jillian M. Haines16
| Anne S. Hale17 | Alice A. Huang18 | John M. Lucy 19
|
Shana K. O’Marra20
| Elizabeth A. Rozanski15
| John M. Thomason 4
|
Jenny E. Walton21 | Helen E. Wilson 22
Correspondence
Robert Goggs, Department of Clinical
Sciences, Cornell University College of
Veterinary Medicine, S1-068 Schurman Hall,
240 Farrier Road, Ithaca, NY 14853, USA.
Email: [email protected]
Abstract
Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but
there are no evidence-based guidelines to assist clinicians with treatment decisions.
Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include
secondary immunosuppressive drugs such as azathioprine, modified cyclosporine,
Abbreviations: ABCB1, ATP binding cassette subfamily B member 1; CBC, complete blood cell count; CR, complete response; DOGiBAT, daily canine bleeding assessment tool; hIVIg, human IV
immunoglobulin; IMHA, immune-mediated hemolytic anemia; ITP, immune thrombocytopenia; MDR1, multidrug resistance 1; MMF, mycophenolate mofetil; NR, no response; NSAID,
nonsteroidal anti-inflammatory drug; PICO, Population Intervention Comparison Outcome; pITP, primary immune thrombocytopenia; PR, partial response; sITP, secondary immune
thrombocytopenia; TEG, thromboelastography; TPE, therapeutic plasma exchange; TPO, thrombopoietin.
Dana N. LeVine, Linda Kidd, and Oliver A. Garden are co-chairs on the Consensus Statement.
Dana N. LeVine, Robert Goggs, Barbara Kohn, and Andrew J. Mackin share first authorship.
Marjory B. Brooks, Robert Goggs, Barbara Kohn, and Andrew J. Mackin are panel members on the Consensus Statement.
Erin R. B. Eldermire, Anthony Abrams-Ogg, Elizabeth H. Appleman, Todd M. Archer, Domenico Bianco, Shauna L. Blois, Benjamin M. Brainard, Mary Beth Callan, Claire L. Fellman, Jillian M.
Haines, Anne S. Hale, Alice A. Huang, John M. Lucy, Shana K. O’Marra, Elizabeth A. Rozanski, John M. Thomason, Jenny E. Walton, and Helen E. Wilson are advisory task force members on the
Consensus Statement.
For affiliations refer to page 2001
Received: 29 March 2024 Accepted: 4 April 2024.
I have it on pdf file,if you cannot find it feel free to email me so i can send it to you.Today i received the sad news that Luna,the little Maltese from Ivana passed away today😢She had a liver tumor.Her age was 14.My heart goes out to Ivana who did so much for her dog child.May she be blessed for that.
Bye for now,Chomissa
Hi Chomissa,
Thank you for the information! I look forward to reading through it and will pass it along to the blog team as well. I am so heartbroken to hear about Luna. Please pass along my condolences to Ivana. ♥
Hi again,
Sorry i copied more then necessary only saw it now.it is the veterinary journal of internal medicine!
Bye!
Chomissa
The comments reference the drug Romiplostim. My dog still has ITP after a long bout of steroid treatment and a splenectomy so my vet wants to try this drug. However, I can’t find a source for it. Can you tell me where you got it? Thanks
Eileen McDonough
Hi Eileen,
I am sorry your pup is not responding well to the traditional treatment for ITP. I have not personally used Romiplostim in my patients and would not know how to obtain it. This comment came through as a reply to my previous reply. Try to see if you can reply to Chomissa directly as she would have better information. Wishing you all the best of luck and praying your boy can make a full recovery. ♥
Hi Dr. Buzby, our golden retriever, Murphy, was diagnosed with ITP in August, we attempted to wean his prednisone in October but he experienced back arching, trembling, and his platelets dropped, and white count went up, our vet put his prednisone back to previous dose and started cyclosporine. He has experienced weight loss from GI upset related to the cyclosporine and muscle wasting from the prednisone so we want to get him to lower doses if possible. We just started attempting to wean again in December and he tolerated the first decrease from 20 mg twice a day, to 20 mg am and 10 mg pm for 3 weeks. We went to 20 mg am and are alternating 10 mg pm every other day, after about a week of this, we have noticed Murphy having some increased joint stiffness and weakness and decreased appetite. Is this something you can see when weaning prednisone? We still have him on the cyclosporine and will check labs again this week. He is eager to eat treats but won’t touch his dry dog food. We just tried wet food and he ate this right away. Could he be correlated the dry food with GI upset from meds? Just wondering if these things are normal responses or not?
Hi Amanda,
I am sorry Murphy has been fighting this terrible disease. From what you describe, I think these new “symptoms” may be a return to normal and that the side effects of the prednisone are starting to decrease. Let me explain…. prednisone causes increased hunger/appetite and can also decrease inflammation from arthritis. So, it makes sense that if the steroids have been decreased that your dog’s appetite would decrease, and that arthritis pain and inflammation could worsen. You may be able to add some wet food to Murphy’s dry kibble to entice him to eat it (if that’s what you prefer) or you could just keep him on a wet diet if that’s what makes him happy. It may be time to include a joint supplement or other therapies to help with arthritis pain. Your vet can help guide you in the right direction. Hoping the weaning process continues to go smoothly and your boy doesn’t experience another relapse. Feel free to keep us updated on Murphy’s condition. Best wishes to you both!
My 4 year old lab was diagnosed with ITP yesterday, at this time primary vs secondary is not known. because of the astronomical cost of her staying at the emergency vet, we opted to bring her home and start on the meds and watch her closely. As a nurse I am familiar with this disease in humans, but our baby girl has us so frightened. Her platelet count was zero yesterday. So I am hoping for a small climb on recheck Monday. I am glad to hear there could be life after this and it is encouraging to read. I am cautiously optimistic that things will improve. She has a brother from the same litter that lives with us and it makes me nervous, is he at an increased risk?
Hi Amanda,
I am sorry your young dog has received this terrible diagnosis. I can only imagine the worry and stress you are feeling right now. It is possible that this is genetic, and her litter mate may end up facing this same issue at some point. I hope the recheck went well your girl was able to respond favorably to the medications. How are things today? Feel free to leave an update if you have a chance. Wishing you all the best of luck and praying for a full recovery.
How do we get in contact with Dr. Laura Garlow please? We are dealing with this new diagnosis for our dog and would be incredibly grateful for the opportunity to communicate with her directly.
Thank you.
Evelien
Hi Evelien,
I am sorry your pup has received this terrible diagnosis. Unfortunately, Dr.Garlow is no longer in private practice and is working in veterinary medicine in a different capacity. Due to this recent change, there is no clinic to contact in order to speak with her directly and I am not able to give out her personal information. You should be able to speak to an internal medicine specialist in your area to receive similar advice as what Dr.Garlow would be able to offer. There are also great sources of information and guidance at the veterinary teaching hospitals in each state. I am sorry I can’t be of more help. Wishing your pup all the best and praying for a positive outcome.
Hi Dr. Buzby,
My 6.5 yo GSD was recently diagnosed with ITP. It was a scary time (still is) as his first sign was a bloody nose. That has since stopped. He’s been put on a steroid. However, in the rush of everything thrown at me and the worry. I cannot remember all that the vet told me to look out for other than tar poop and additional bleeding. I remember the vet says something about internal bleeding but what are signs to rush him to the er for internal bleeding? I noticed a red spot but also not sure if it was there before as it’s hard to see with his coat.
Thank you.
Hi Ashley,
I am so sorry your boy is dealing with this worrisome condition. What a blessing his bloody nose resolved after starting the steroids. Signs of internal bleeding include pale gums, distended abdomen, labored breathing, restlessness, and weakness. You may also notice a lack of appetite if he starts to relapse. Hoping you will never have to worry about this becoming an issue. Wishing your sweet boy all the best and praying he has many happy years ahead.
Hi Dr. Buzby,
Thank you so much for posting so much information about this terrible disease. My sweet girl was diagnosed in Feb 2020. She’s had a few relapses over the years and is going through one right now. It’s been about three years since her last relapse. This time around she doesn’t seem to be responding to the prednisone the way she has in the past. We will re-check her count in 2 more weeks and go up on her pred dose if her platelet count still hasn’t increased. She’s holding steady at 15K, but in the past she would have at least been out of the spontaneous-bleed zone after the two weeks she’s been on this dose.
I’ve been digging into information again like I did the first time and came across some info that suggested cranberry supplements can be problematic in humans with ITP. I have had my girl on OTC cranberry supplements for dogs for a few years now. She’s a rescue, so her age isn’t certain but she’s at least 15.5 and maybe 17.5 years old. The vet didn’t want to add meds for incontinence due to the ITP so the cranberry pills were to mitigate UTI problems. I didn’t think to ask the vet about the cranberry pills, though. I just read the reviews from people saying they helped their geriatric female dogs, and I got them. Now I wonder if I induced this episode in my sweet girl.
I’ve stopped the cranberry pills in case they also may be problematic for ITP in dogs too. Wondered if you’ve come across this link for dogs in your research? Her last blood check was before I found the cranberry info so I’m hoping against hope that the new check, without the cranberry pills, will finally show her platelets rising again.
Dear Nee,
I am sorry your girl is experiencing a relapse of her ITP. Before reading your comment, I had never heard of cranberry causing any issues with dogs living with ITP. I tried to see if I could find any information on the subject, but all of my research came up empty. While I can’t rule it out completely, I would be surprised if the cranberry had anything to do with this relapse. I understand your concern for your pup, especially since she is not responding to the medications as expected. Hoping her body can stabilize and start to get things back on track. Wishing you both nothing but the best and praying for a full recovery.
Thank you so much for responding Dr. Buzbee! Your care and compassion are appreciated more than you probably know. I’m delighted to share that my sweet girl finally started to respond to the pred. She is very much out of the danger zone she was in (4K!). Last check her platelets were back to 167K. I think in trying to find anything that might be a cause, and therefore might be something to change, I was/am desperately hoping for something in my control to help her.
I know she’s approaching the end of her time here on earth just because of her age, and I’m trying to prepare myself for that, but as we all know – it’s just so hard. I greedily want any extra time I can have with her as long as her quality of life is good too. For now, she’s back to aggravating the cat and enjoying her stuffed ducky.
May we all hope to someday be as good as dogs. Sending you much gratitude!
Nee
Hi Nee,
Yay! I am so glad your girl is feeling better and is showing improvement in her platelet numbers. Thank you for the update and the kind words. Continuing to pray for healing for your sweet girl. Keep up the good work!
Hi there, my girl is 3 month 10 years of age. I just wanted to understand if hospitalisation is generally necessary for this? My girl had slight bruising 2 weeks ago and the vet was convinced it was dermatitis. It cleared up within 4 days and then nothing for about 1 week. Two days ago she spontaneously had bruising in small patches on her back. Barely anything on her stomach, gums fine no bleeding urine fine and stool. I rushed her in and they did bloods and her bloods were normal except the platelets which was 24,000-30,000 they confirmed the test the next day and started her on steroids the day after I took her to get seen. They never told me she needed to stay in, just to do a recheck this coming Friday. I guess what I’m trying to understand is, did I catch it with enough platelets left that, that along with absence of symptoms indicate it’s not as severe and the hospital stay isn’t required? Do the steroids tend to stop it getting worse in the meantime?
Hi Miriam,
I understand your concern for your pup and think it is good you are searching for advice. Most dogs require some length of hospitalization for this condition but not ALL. It is possible that since you were able to catch this early and your girl’s platelet numbers have not dropped to near zero that she can be managed at home. The steroids are the main treatment for ITP as they are suppressing the immune system and trying to prevent the body from destroying platelets. Your girl may end up needing to take them long term or your vet might choose to switch her to a different immunosuppressive medication if the side effects become an issue. How are things today? Hoping all is well and praying your girl was able to make a full recovery.
Hello all, I can’t begin to tell you how grateful I am to have happened upon this site and your discussions. My 7 year old Papillon was diagnosed with ITP in June and was responding well to Prednisone, so much so that we had gradually been able to reduce her prednisone from 1 and 1/2 pills every 12 hours down to 1/4 pill every other day with regular blood tests. An ultrasound showed thickening of the lining of her bladder and as she has consistently had trace blood in her urine although not a UTI we started her on a natural supplement that contains cranberries on November 18th… on November 24th I noticed a red bruise on her belly and a blood test on November 26th told us that she had relapsed and her white platelet count was dangerously low again, so she’s now back on 1 and 1/2 prednisone twice a day and goes back tomorrow to check if her counts have risen. I’m not saying that the cranberries had anything to do with it, but she had been doing fine until then. I know that it could have just been too low a dose of prednisone for her and that 1/2 a tablet every other day was her sweet spot, but I have to wonder about the cranberry thing.
Hi Amanda,
I am sorry your girl has experienced a relapse of her ITP. I am glad you are being cautious and trying to remove any possible triggers from her daily routine. I am not aware of cranberry causing issues with bleeding or having negative effects on the immune system. The timing of this episode was probably a coincidence. I hate your girl is battling low platelets again. Hoping she will stabilize quickly and praying for a full recovery. Feel free to leave an update and let us know how things are going.
We have a 2yr old neutered collie who had a nose bleed on 5th July. We called the vets who said it wasn’t urgent and saw him the following week. On 10th July they told us his platelets were 4000, and he started prednisone on 12th July. After 5 days of prednisone he had repeat bloods and his platelet count has not improved. The vets have suggested one week of higher dose pred plus another immuno-suppressant, and said that’s the final resort. Is it kinder to euthanise if his levels remain at 4000? He is showing no symptoms (other than the one nose bleed which stopped within 30minutes). He is a rescue and is having to be sedated at the vets, so it’s a traumatising experience and the vets want to check his platelet levels frequently.
Dear Alex,
I am sorry you are facing this difficult situation with your young Collie. It is hard to know what would be best without playing a personal role in his medical care. If your boy is not having any symptoms and seems to be feeling well, I am not sure euthanasia is needed at this point. I do realize that if his platelet numbers drop you could end up in a life-threatening situation with little to no warning. Unfortunately, some problems just don’t have a definitive right or wrong way to handle them. I will be praying for clarity and strength as you navigate this unknown path. Wishing you both nothing but the best and holding on to hope for a full recovery for your sweet boy.
Hi Dr. Buzby,
I am so thankful for you and for this article. Elsie, our 8-year-old female toy poodle, is in the hospital with suspected completely primary ITP. Her platelet count was zero with RBC 16% down from 29% admitted yesterday. She was lethargic for a few days (she was diagnosed with pancreatitis a few months ago and since then has good spells and lethargic spells, but always came out of it until now). She has abdominal petechiae, corneal bleeding. She is very alert, and barks when we leave from visiting her. She has had 1 transfusion with vincristine, as well as steroid/antibiotic, and immunosuppressant (mycophenolate) and anti-nausea. She’s eating and drinking. Her gall bladder was enlarged during an ultrasound and they think that is why perhaps pancreatitis blood marker is high right now.
1. Do you feel that this could have been the same issue that we were dealing with in November back at our GP vet (diagnosed with a blood test after I complained of lethargy and upset stomach)? Or did we have two unrelated issues? I didn’t know if you’ve seen that before.
2. I am certain my hospital will recommend to keep her there until her platelet count is around 50,000. The cost is just so incredibly expensive for us- but we love her so (first “adult” dog). I wonder if we could take her home after a few days, even with low platelets, and be extremely careful with her and begin at-home treatment.
I’m so grateful with any response you may have.
Hi Raquel,
I am so sorry you are facing this difficult situation with Elise. I understand your concern for her wellbeing and your finances. It is possible this was contributing to the issues she was facing back in November, but there really is no way to know for sure. Taking her home to continue treatment may be an option. There is no way to predict how she will respond without giving it a try. I encourage you to discuss this with your vet and get their expert opinion. They will let you know when they think she can be released with the least amount of potential negative consequences. Praying for healing and a positive outcome for your sweet girl. Feel free to keep us updated on how things are going.
Dr Buzby,
Thank you for your very informative article. My friend’s dog just died of ITP. He was 3 years old. His groomer was the first to observe discoloration of the gums and some spots on his body, and told my friend that she was concerned because she suspected ITP. This was yesterday and my friend took him immediately to the emergency vet. He was perfectly normal otherwise, but his platelet count was very low. They decided to keep him overnight and administered Vincristine. He also received a transfusion. How common is for things to deteriorate so rapidly? He didn’t have any symptoms at all. We are in such a shock.
Dear Sonia,
I am sorry your friend lost their pup in such a tragic way. They are lucky to have someone like you in their life who is willing to search for answers and offer support. Unfortunately, this disease is very unpredictable, and things can change rapidly. Some dogs just don’t respond to treatment and then pass fairly quickly. Your friend did everything they could for their boy, and I am certain he knew how much he was loved. I hope with time the grief will begin to fade and you can take comfort in the memories of all the good times you shared. Wishing you brighter days ahead. Bless you all. ♥
Hi Dr Buzby,
What a wonderful resource that is available here for Dogs with ITP.
Our almost 14 year old 20kg labradoodle had a platelet count of 2 about three weeks ago. He was very lethargic and not eating. Vet diagnosed him with critical platelet count and started 20mg prednisone and doxy. Also we had full xrays, ultrasound, and blood work. Vet referred us to emergency hospital to treat him and hospitalize him , but we brought him home with the medicines and he responded very well. Back to eating with an astonishing appetite I have never seen in him before. Recheck a week later his platelets were 800. Lowered the dose of prednisone to 15 mg from 20mg and about a week later I noticed a nose bleed and his gums bleeding within a day. Lenny went back to the vet , this time he as at 0. Vet went back up to 20mg prednisone , and added 20 mg of Leflunomide, and also recommended 3mg melatonin. He still has his appetite and seems to be responding ok. Took him for a 2 mile walk today and he seems like his normal self. I also started feeding him raw flank steak.
The vet doesn’t think its cancer but most likely auto immune or another cause. I don’t think even if we put him through the paces looking for the cause of his ITP would the treatment course change? Lenny has always been a health active dog with minimal problems over his life. I know we are in bonus time with him at 14 years old , but I am worried his platelets will drop again. Any info appreciated.
Hi Casey,
I understand your concern for your senior guy and think he is very lucky to have you taking such good care of him. I am not sure the treatment would change if you found out cancer was the culprit, but it could have a big impact on the prognosis or life expectancy. It is possible for relapses to occur, but it sounds like you are doing everything you can to keep this from happening. Your vet is doing a great job of staying on top of things and being proactive with treatment and testing. Wishing you all the best as you navigate this tricky path. Praying for continued success and many happy days ahead for your sweet boy.
Hi Dr Buzby,
Today another update on Mowgli after a while.Mowgli is still doing good,platelets are about 450 and we are only giving him 0.02 of Romiplostime every 21 days.At the end of this month we will make an ultrasound of his spleen just to see if anything has changed since last year out of precaution.I did tell you before that Mowgli was having major food intolerance since he was a puppy and that i had tried all sorts of food just in hopes that there was anything that he would respond to in a positive way.Since a half year i have him on Royal Canin Hypoallergene and freeze dried ducky bites,plus horsemilk and vitamine B 12 ,vitamin B 9 and probiotica.Ever since i have started giving him all of this his food intolerance went away,so nomore vomitting and diarrhea and nomore ear infections and anal gland problems I wished i had done this before! Now i came across an interesting article that gave me an Aha moment and i just wonder that if any of the other dogs owners were or are experiencing the same issues with their dogs that got struck with ITP as the ones i mentioned in here I will insert the article but i am getting more and more convinced that ITP that is immune mediated has a correlation with a microbiome that is our of balance.I think that we have to think very well what we feed our animals with.After all,we are what we eat right and health overall starts in the gut.I am curious to know your view on this 😃Bye for now and i will keep you posted
Greets,Chomissa
https://animalmicrobiome.biomedcentral.com/articles/10.1186/s42523-023-00268-2#:~:text=IMHA%2FITP%20is%20associated%20with,and%20increased%20overall%20microbial%20diversity.
Hi Chomissa,
I am glad to hear Mowgli is doing well and things are maintaining with the romiplostim injections. This is very interesting information! I agree that gut health is very important and affects far more than what most people are aware of. I briefly looked over the study from the link you attached. It was done with a very small population of dogs and is unfortunate that not all were facing the same disease. I am also concerned that some of the dogs in the study received antibiotics while others did not. I wonder how much this affected the results. I know this was just a pilot study and am glad scientists are staring to pay more attention to this topic. I think we have so much to learn and hope they will continue to dig deeper into this subject. Thank you for sharing. As always, I look forward to our next conversation!
I had a border collie diagnosed in September 2023 who unfortunately just didn’t respond to medication and blood transfusions didn’t help. Then 4 months later our pitty/mastiff also got diagnosed with ITP he spent 4 different occasions in the emergency vet and finally we have seen progress. He has been tapering off medication for 5 months now but he has lost a lot of muscle mass, gained a lot of weight, so many UTIs and ear infections. Is it a normal thing to see so many UTIs and blood count fluctuations? He is almost off prednisone and finally playing again.
Hi Toni,
I am sorry you have been through so much over the past year and wish your boy could be spared from this terrible condition. Unfortunately, treating ITP requires suppressing the immune system. With immunosuppression also comes the risk of infections and side effects from the medications. I would suspect the UTIs and ear infections are a consequence of the immune suppression, and loss of muscle mass and weight gain are side effects of prednisone. Blood count fluctuations are very common and can be an ongoing battle with ITP. I am hopeful that your boy can continue to improve and that his symptoms will subside once the prednisone is discontinued. Praying for healing and wishing your sweet boy all the best at making a full recovery.
Thank you for posting this article! I’ve taken some comfort from it and learned more than elsewhere.
Our German Shepherd puppy was diagnosed at 4 months old. Although we’ve gotten his platelets up from then (platelets were at zero, pup is now 10 months old, platelets up and down), our vet wants him off of prednisone, understandably, and the mycophenolate did nothing. The ONLY symptom he ever displayed was slight lethargy. Nothing else. The vets at the clinic and the technicians at the lab were all stunned-prompting several repeat tests. He’s our joy and deserves a normal life. We had to end all vaccinations, which means his “playmates” are very limited. Do you have any advice? Do you know of any other cases so young? I could only find one online, and that case had a host of other comorbidities.
Thanks for your time!
Hi Karen,
I am so sorry you had to deal with this terrible disease in your puppy! I have never seen ITP in a dog that young. If you aren’t already working with an internal medicine specialist, I would recommend you get established as a patient. A specialist could be extremely valuable if your pup ends up having another episode. Hoping your Shepherd will go on to live a normal life and this will all be a thing of the past. Best wishes and take care!
Hi Karen,
I have written a lot of information about my 7 year old Shih Tzu who was diagnosed with immune mediated ITP last year.After finding an article of a German University who had done a trial with 5 dogs in humane medication i convinced my dog’s internist to give it a try and immediately my dog went in remission.If you want more information you can either scroll down the comments and read my messages or you can email me on [email protected] and i can send you information about it.I advise you also to start giving your dog Vitamine B 12 and follic acidB 9 and probiotica supplement to help his microbiome.get into the best shape.
Greets,Chomissa