ACVIM consensus statement on the treatment of immune-mediated hemolytic anemia in dogs

Abstract

Immune-mediated hemolytic anemia (IMHA) causes severe anemia in dogs and is associated with considerable morbidity and mortality. Treatment with various immunosuppressive and antithrombotic drugs has been described anecdotally and in previous studies, but little consensus exists among veterinarians as to the optimal regimen to employ and maintain after diagnosis of the disease. To address this inconsistency and provide evidence-based guidelines for treatment of IMHA in dogs, we identified and extracted data from studies published in the veterinary literature. We developed a novel tool for evaluation of evidence quality, using it to assess study design, diagnostic criteria, explanation of treatment regimens, and validity of statistical methods. In combination with our clinical experience and comparable guidelines for humans afflicted with autoimmune hemolytic anemia, we used the conclusions of this process to make a set of clinical recommendations regarding treatment of IMHA in dogs, which we refined subsequently by conducting several iterations of Delphi review. Additionally, we considered emerging treatments for IMHA in dogs and highlighted areas deserving of future research. Comments were solicited from several professional bodies to maximize clinical applicability before the recommendations were submitted for publication. The resulting document is intended to provide clinical guidelines for management of IMHA in dogs. These guidelines should be implemented pragmatically, with consideration of animal, owner, and veterinary factors that may vary among cases.

Keywords: AIHA; IMHA; azathioprine; canine; cyclosporine; guideline; mycophenolate mofetil; prednisolone.

Figure 1

Flow diagram indicating flow of information used in the systematic review. Diagram produced using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement12

Figure 2

Results of evidence quality assessment for studies investigating the use of blood products in dogs with immune‐mediated hemolytic anemia (IMHA). RCT, randomized controlled trial

Figure 3

Flow diagram showing recommended approach for initial treatment of dogs with immune‐mediated hemolytic anemia (IMHA). IVIG, intravenous immunoglobulin; TDM, therapeutic drug monitoring. Various outcomes make reference to Consensus Summary Statement #14, to which the reader is referred for further information

Figure 4

Results of evidence quality assessment for studies investigating the use of immunosuppressive drugs in dogs with immune‐mediated hemolytic anemia (IMHA). RCT, randomized controlled trial

Figure 5

Results of evidence quality assessment for studies investigating the use of intravenous immunoglobulin in dogs with immune‐mediated hemolytic anemia (IMHA). RCT, randomized controlled trial

Figure 6

Flow diagram showing recommended approach for management of relapse in dogs with immune‐mediated hemolytic anemia (IMHA). IVIG, intravenous immunoglobulin; TDM, therapeutic drug monitoring. Various outcomes make reference to Consensus Summary Statement #33, to which the reader is referred for further information

Figure 7

Algorithm showing recommended approach to selection of antithrombotic drugs for dogs with immune‐mediated hemolytic anemia (IMHA). LMW, low molecular weight

Figure 8

Results of evidence quality assessment for studies investigating the use of antithrombotic drugs in dogs with immune‐mediated hemolytic anemia (IMHA). RCT, randomized controlled trial