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Azathioprine in dogs with IMHA

Clinical Scenario

Bruce is a 4 year old German shepherd dog (GSD) cross who has presented to you with a severe anaemia which you think is haemolytic. His PCV was 16% and he is Coombs positive. You are going to put him on prednisolone and you wonder about also using azathioprine but Bruce’s owner has very little money. You wonder if adding the azathioprine would improve his chance of survival...

3-Part Question (PICO)

In [dogs with immune-mediated haemolytic anaemia] does the use of [azathioprine 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 azathioprine.mp. OR exp Azathioprine/)

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 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 azathioprine.mp.)

Search Outcome

MEDLINE

  • 57 papers found in MEDLINE search
  • 55 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

  • 79 papers found in CAB search
  • 75 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 1 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

Only one paper, a systematic review, is included in the summary of evidence as the other two relevant papers were included in the systematic review.

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
  • Two retrospective cohort studies and one prospective cohort study included, comparing prednisolone vs prednisolone and azathioprine
  • No studies indicated an advantage in using azathioprine 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 for unpublished literature was reported
  • No attempts were made to obtain ‘missing’ information from the included studies
Attachment:
No attachments.

Comments

As a systematic review was available that included all the other relevant studies found in the searches, this was the only paper used in the evidence summary. The systematic review was unable to come to any firm conclusions due to the quality and level of evidence available. There is a need for a high quality randomised control trial in this topic in order to help answer this question. It should be noted that azathioprine is not currently licensed for veterinary use in the UK.

Bottom line

No evidence exists showing a benefit of using azathioprine with prednisolone as opposed to prednisolone alone for the treatment of IMHA, and in this clinical situation it is feasible to keep Bruce on prednisolone alone and not to start using azathioprine therapy.

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 19:02:56
Original publication date:
2013-09-13 19:02:56
Last updated:
2016-10-24 19:02:56
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