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Cyclophosphamide in dogs with IMHA

Clinical Scenario

Sally is a 5 year old Springer Spaniel who has presented to you with severe immune mediated haemolytic anaemia (IMHA). Her PCV was 12% and you could see her red blood cells haemolysing on a slide agglutination test. You have already given her a blood transfusion and started her on 2 mg/kg prednisolone twice a day. She is also on gastro protectants. She is quite bright but very weak. A colleague who is studying for a medicine certificate has suggested you use some cyclophosphamide as well. You wonder if this will improve Sally’s chance of survival...

3-Part Question (PICO)

In [dogs with immune-mediated haemolytic anaemia] does the use of [cyclophosphamide in addition to prednisolone compared to prednisolone alone] [increase the chance of survival]?

Search Strategy and Summary of Evidence

Search Strategy

MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) 1946 to Present using the OVID interface

(dog.mp. OR dogs.mp. OR canine.mp. OR canines.mp. OR canis.mp. OR canid.mp. OR canids.mp. OR canidae.mp. OR exp Dogs/ OR exp Canidae/)

AND

(haemolytic anaemia.mp. OR hemolytic anemia.mp. OR IMHA.mp. OR AIHA.mp. OR exp Anemia, Hemolytic, Autoimmune/ OR exp Anemia, Hemolytic/)

AND

(prednisolone.mp. OR prednisone.mp. OR exp Prednisolone/ OR cyclophosphamide.mp. OR exp Cyclophosphamide/)

CAB Abstracts 1910 to Present using the OVID interface

(dog.mp. OR dogs.mp. OR canine.mp. OR canines.mp. OR canis.mp. OR canid.mp. OR canids.mp. OR canidae.mp. OR exp dogs/ OR exp canis/ OR exp canidae/)

AND

(haemolytic anaemia.mp. OR hemolytic anemia.mp. OR IMHA.mp. OR AIHA.mp. OR exp haemolytic anaemia/)

AND

(prednisolone.mp. OR prednisone.mp. OR exp prednisolone/ OR cyclophosphamide.mp. OR exp cyclophosphamide/)

Search Outcome

MEDLINE

  • 51 papers found in MEDLINE search
  • 49 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 0 papers excluded as they are review articles/in vitro research/conference proceedings
  • 2 total relevant papers from MEDLINE

CAB Abstracts

  • 74 papers found in CAB search
  • 68 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 3 papers excluded as they are review articles/in vitro research/conference proceedings
  • 3 total relevant papers from CAB

Total relevant papers

3 relevant papers from both MEDLINE and CAB Abstracts

Comments

As a systematic review was available that included all the relevant studies found in the searches, this was the only paper used in the evidence summary.

Summary of Evidence

Swann and Skelly, 2013

Title:

Systematic review of evidence relating to the treatment of immune-mediated hemolytic anemia in dogs.

Patient group:

Dogs with primary idiopathic IMHA

Study Type:

Systematic review

Outcomes:
  • Outcome of therapeutic regimens including survival of individual treatment groups
Key Results:
  • The studies examined were generally of poor quality.
  • Evidence too weak to form firm conclusions.
  • One small RCT and two retrospective studies discussed concerning prednisolone vs prednisolone and cyclophosphamide.
  • No studies indicated an advantage in using cyclophosphamide and prednisolone compared to prednisolone alone in relation to survival.
  • The use of glucocorticoids alone will result in a successful outcome in a high proportion of cases.
Study Weaknesses:
  • More extensive search terms could have been used.
  • No searching of unpublished literature was reported.
  • No attempts were made to obtain ‘missing’ information from the included studies.
  • Paper included in the practical considerations section not included and appraised in the systematic review tables.
Attachment:
No attachments.

Comments

The systematic review was unable to come to any firm conclusions due to the quality and level of evidence presented to it. There is a need for a high quality randomised control trial on this topic in order to help answer this question. It should be noted that cyclophosphamide is not currently licensed for veterinary use in the UK.

Bottom line

No evidence exists showing a benefit of using cyclophosphamide with prednisolone as opposed to prednisolone alone for the treatment of IMHA.

Disclaimer

The BETs on this website are a summary of the evidence found on a topic and are not clinical guidelines. It is the responsibility of the individual veterinary surgeon to ensure appropriate decisions are made based on the specific circumstances of patients under their care, taking into account other factors such as local licensing regulations. Read small print

References

Swann JW, Skelly BJ, (2013). Systematic review of evidence relating to the treatment of immune-mediated hemolytic anemia in dogs. Journal of Veterinary Internal Medicine 27: 1–9.

About this BET

First author:
Martin Downes
Second author:
Kathryn Wareham
Institution:

CEVM, University of Nottingham

Search last performed:
2016-10-24 19:15:39
Original publication date:
2014-01-30 19:15:39
Last updated:
2016-10-24 19:15:39
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