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Suggest Alternative Treatment For Autoimmune Hemolytic Anemia
Question: My son was diagnosed with Aiha and treated with prednisone high dose. He was tapered off the drug but the blood work shows it isn't gone away. What other treatments are available? I was told a virus caused the onset but it should have cleared up by now. The virus is gone but his body still has hemoltosys and is still Coombs positive. What else can be causing this. Lupus test negative
Brief Answer:
Extended steroid therapy, Rituximab , splenectomy are some options.
Detailed Answer:
hello sir,
Thank you for your detailed reply.
I can empathize with your son's condition.
Autoimmune hemolytic anemias can be due to varied causes sir. However, for simplicity sake it can be seen as caused by IgG type(warm or cold) or IgM type (only cold, c3 mediated)antibody. Both have multiple potential causes and many times a specific cause can not be assigned.
It is first important to determine which antibody is causing the hemolysis by certain laboratory coomb test. It helps in determining treatment.
If it is IgM type of antibody then Rituximab and avoidance to cold may work wonders for your kid and prednisone may not work at all.
If it is IgG type of antibody then after 2-3 weeks of prednisone trial if there is no result the best that could work is a trial with rituximab medication which attacks b lymphocytes of body. Another later options are spleen removal, danazol, azathioprine or exchange transfusion.
So all in all,
I would recommend you to discuss with your hematologist//doctor and determine which antibody is causing it (IgG or IgM) and then take appropriate guidance and steps from there on to prevent further attacks.
Also if the hemoglobin suddenly goes low or his urine turns red please ensure adequate hydration by giving him water to help his kidneys flush out hemoglobin as it is toxic to kidneys. Also transfusion may be necessary to maintain hemoglobin levels acutely.
I hope this helps.
Wish you all the best sir.
Let me know if you have any more questions or concerns.
Sincerely,
Dr Parth Desai
Extended steroid therapy, Rituximab , splenectomy are some options.
Detailed Answer:
hello sir,
Thank you for your detailed reply.
I can empathize with your son's condition.
Autoimmune hemolytic anemias can be due to varied causes sir. However, for simplicity sake it can be seen as caused by IgG type(warm or cold) or IgM type (only cold, c3 mediated)antibody. Both have multiple potential causes and many times a specific cause can not be assigned.
It is first important to determine which antibody is causing the hemolysis by certain laboratory coomb test. It helps in determining treatment.
If it is IgM type of antibody then Rituximab and avoidance to cold may work wonders for your kid and prednisone may not work at all.
If it is IgG type of antibody then after 2-3 weeks of prednisone trial if there is no result the best that could work is a trial with rituximab medication which attacks b lymphocytes of body. Another later options are spleen removal, danazol, azathioprine or exchange transfusion.
So all in all,
I would recommend you to discuss with your hematologist//doctor and determine which antibody is causing it (IgG or IgM) and then take appropriate guidance and steps from there on to prevent further attacks.
Also if the hemoglobin suddenly goes low or his urine turns red please ensure adequate hydration by giving him water to help his kidneys flush out hemoglobin as it is toxic to kidneys. Also transfusion may be necessary to maintain hemoglobin levels acutely.
I hope this helps.
Wish you all the best sir.
Let me know if you have any more questions or concerns.
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by :
Dr. Shanthi.E
Hello
He has warm AIHA, he has been on prednisone for 10 weeks, at the beginning of his symptoms he had 5 blood transfusions to bring up his level to 100. When he was weaned off the meds his levels started to drop again, so I don't think the prednisone worked.
What else could be causing this to happen? They said the HHV6 virrus tested positive and then they stopped looking cause he was going to get better in a few days.
What other test can be run to find the primary cause? He just had blood work and an abdominal ultrasound.
the doctor suggested MMF and more Prendisone but my research shows if prednisone wont work by now, it wont work and MMF will just prevent the antibodies from attaching to the blood so we aren't addressing the problem.
We are to see the hematologist next week, I want to make sure I am prepared with the right questions, and right requests.
He has warm AIHA, he has been on prednisone for 10 weeks, at the beginning of his symptoms he had 5 blood transfusions to bring up his level to 100. When he was weaned off the meds his levels started to drop again, so I don't think the prednisone worked.
What else could be causing this to happen? They said the HHV6 virrus tested positive and then they stopped looking cause he was going to get better in a few days.
What other test can be run to find the primary cause? He just had blood work and an abdominal ultrasound.
the doctor suggested MMF and more Prendisone but my research shows if prednisone wont work by now, it wont work and MMF will just prevent the antibodies from attaching to the blood so we aren't addressing the problem.
We are to see the hematologist next week, I want to make sure I am prepared with the right questions, and right requests.
Brief Answer:
It is mostly due to recent viral infection. Discuss about Rituximab
Detailed Answer:
Hello sir,
Thank you for your reply query.
Warm AIHA in children is most commonly due to viral infections like influenza, EBV virus, CMV, HHV virus and so on. It can also be due to lymphoid disorders and that needs to be evaluated. Ask your doctor if he can feel any swelling in neck, axilla or groin or examination. A routine chest xray will also help.
Other causes of warm AIHA in children is autoimmune disorders like lupus which you mentioned the tests were negative. The best test would be ANA followed by Ds DNA or Anti XXXXXXX assay.
However, in few childre there is no cause that is determined and it is known as primary warm AIHA.
The treatment if the steroid shots do not work, is then to fall on Rituximab or immunomodulators like MMF advised.
Some times exchange transfusion works by removing antibody but that is only a temporary measure.
Long term management should include the option of splenectomy as in WARM AIHA spleen is the main site of RBC destruction.
But all these treatments may make the child susceptible to certain infections. So I would recommend you talk with your doctor about that and after examination he can start the best possible newer treatment with certain infection preventing precautions.
So all in all I would recommend to-
1) Discuss about ruling out a lymphoid disorder by examination, xray or bone marrow if required.
2) Discuss about Rituximab or splenectomy as an option to MMF.
3) Discuss about how he will manage the long term side effects of these treatment options.
I hope this helps.
Wish you all the best.
Let me know if you have any more questions or concerns sir
Sincerely,
Dr Parth Desai
It is mostly due to recent viral infection. Discuss about Rituximab
Detailed Answer:
Hello sir,
Thank you for your reply query.
Warm AIHA in children is most commonly due to viral infections like influenza, EBV virus, CMV, HHV virus and so on. It can also be due to lymphoid disorders and that needs to be evaluated. Ask your doctor if he can feel any swelling in neck, axilla or groin or examination. A routine chest xray will also help.
Other causes of warm AIHA in children is autoimmune disorders like lupus which you mentioned the tests were negative. The best test would be ANA followed by Ds DNA or Anti XXXXXXX assay.
However, in few childre there is no cause that is determined and it is known as primary warm AIHA.
The treatment if the steroid shots do not work, is then to fall on Rituximab or immunomodulators like MMF advised.
Some times exchange transfusion works by removing antibody but that is only a temporary measure.
Long term management should include the option of splenectomy as in WARM AIHA spleen is the main site of RBC destruction.
But all these treatments may make the child susceptible to certain infections. So I would recommend you talk with your doctor about that and after examination he can start the best possible newer treatment with certain infection preventing precautions.
So all in all I would recommend to-
1) Discuss about ruling out a lymphoid disorder by examination, xray or bone marrow if required.
2) Discuss about Rituximab or splenectomy as an option to MMF.
3) Discuss about how he will manage the long term side effects of these treatment options.
I hope this helps.
Wish you all the best.
Let me know if you have any more questions or concerns sir
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by :
Dr. Neel Kudchadkar
thank you, I will take note and discuss these with the doctor as your suggestions are helpful
Brief Answer:
Please Let me know about the health of your child in future
Detailed Answer:
Hello sir,
Thank you for your reply.
Please do discuss with the doctor and let me know the condition of your boy after newer treatment is substantiated.
I wish you and your family all the best
Let me know if you have any more questions or concern Sir.
Sincerely,
Dr Parth Desai
Please Let me know about the health of your child in future
Detailed Answer:
Hello sir,
Thank you for your reply.
Please do discuss with the doctor and let me know the condition of your boy after newer treatment is substantiated.
I wish you and your family all the best
Let me know if you have any more questions or concern Sir.
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
I also wanted to ask
Is there a way to tell from the blood tests that are provided if any cancers could be suspected? Leukemia etc. I am not sure what levels are considered really high, when I asked the hematologist he said they weren't high and other levels weren't really low. Yet they fall outside normal range
Is there a way to tell from the blood tests that are provided if any cancers could be suspected? Leukemia etc. I am not sure what levels are considered really high, when I asked the hematologist he said they weren't high and other levels weren't really low. Yet they fall outside normal range
Brief Answer:
The bloodwork report indicates low chances of leukemia
Detailed Answer:
Hello sir
Thank you for your reply query.
The bloodwork report shows normal or occasionally slightly elevated WBC counts.. Also the platelet count is normal. LDH is elevated but that is seen in hemolysis too.
So chances of leukemia are low.
However, the best way to rule out lymphoma or leukemia is bone marrow biopsy and aspiration and flowcytometry of peripheral blood or bone marrow if anything suspicious. Also if your child has any neck or axillary or groin swellings or xrays show any enlarged mediastinal lymphnodes or abdominal lymphnodes on ultrasound then further studies in form of biopsy can rule out lymphomas.
Lymphomas can cause AIHA and discuss with your doctor to rule that possibility out although it is infrequent in kids.
I hope this helps sir
Let me know if you have any more questions or concerns.
Wish you all the best.
Sincerely,
Dr Parth Desai
The bloodwork report indicates low chances of leukemia
Detailed Answer:
Hello sir
Thank you for your reply query.
The bloodwork report shows normal or occasionally slightly elevated WBC counts.. Also the platelet count is normal. LDH is elevated but that is seen in hemolysis too.
So chances of leukemia are low.
However, the best way to rule out lymphoma or leukemia is bone marrow biopsy and aspiration and flowcytometry of peripheral blood or bone marrow if anything suspicious. Also if your child has any neck or axillary or groin swellings or xrays show any enlarged mediastinal lymphnodes or abdominal lymphnodes on ultrasound then further studies in form of biopsy can rule out lymphomas.
Lymphomas can cause AIHA and discuss with your doctor to rule that possibility out although it is infrequent in kids.
I hope this helps sir
Let me know if you have any more questions or concerns.
Wish you all the best.
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Excellent, thank you
Brief Answer:
Please provide me feedback of your kids health
Detailed Answer:
Hello sir,
You are welcome.
Please let me know if you have any more questions or concerns.
Also please let me know about followup of your childs health.
wish you all the best
Sincerely,
Dr Parth Desai
Please provide me feedback of your kids health
Detailed Answer:
Hello sir,
You are welcome.
Please let me know if you have any more questions or concerns.
Also please let me know about followup of your childs health.
wish you all the best
Sincerely,
Dr Parth Desai
Above answer was peer-reviewed by :
Dr. Prasad
Hello
We saw the hematologist and my sons blood work shows another improvement. He has agreed that a low dose of prendisone for a few more weeks is advisable since his numbers continue to improve. He said that adding MMF to his treatment is the best option as the other treatments have too many risks. He said there is slight risk to the kidneys but very small. He said he can stay on this drug for many years.I have tried to research this drug but i can only find bad things about it. Is it safe for a boy of 7.
We saw the hematologist and my sons blood work shows another improvement. He has agreed that a low dose of prendisone for a few more weeks is advisable since his numbers continue to improve. He said that adding MMF to his treatment is the best option as the other treatments have too many risks. He said there is slight risk to the kidneys but very small. He said he can stay on this drug for many years.I have tried to research this drug but i can only find bad things about it. Is it safe for a boy of 7.
Brief Answer:
Data on MMF in pediatric AIHA is very small but positive
Detailed Answer:
Hello sir,
thank you for your feedback and query.
Any immunosuppressive therapy for Autoimmune disorders has certain fixed risks of side effects. They all increase the chances of viral, bacterial and fungal infections. So is the risk with MMF. Apart from that there is a small risk for of developing lymphoma and a small risk for renal disease.
however, few people have tried using MMF in kids as an adjunct to prednisone to reduce the dose of steroids so that patients are relieved from long term sideeffects of steroids. the results have been promising in the small studies conducted.
I do not have much personal experience with MMF. Since his counts are improving with steroids alone it is a positive sign and may be MMF may be added at lowest possible dose later on to reduce the dose of prednisone.
Yet, I would again recommend you to discuss with your doctor regarding rituximab or splenectomy as an option in terms of long term therapy.
Let me know the feedback of your child sir.
Also let me know if you have any more questions or concerns.
Wish you all the best.
Sincerely,
Dr Parth Desai
Data on MMF in pediatric AIHA is very small but positive
Detailed Answer:
Hello sir,
thank you for your feedback and query.
Any immunosuppressive therapy for Autoimmune disorders has certain fixed risks of side effects. They all increase the chances of viral, bacterial and fungal infections. So is the risk with MMF. Apart from that there is a small risk for of developing lymphoma and a small risk for renal disease.
however, few people have tried using MMF in kids as an adjunct to prednisone to reduce the dose of steroids so that patients are relieved from long term sideeffects of steroids. the results have been promising in the small studies conducted.
I do not have much personal experience with MMF. Since his counts are improving with steroids alone it is a positive sign and may be MMF may be added at lowest possible dose later on to reduce the dose of prednisone.
Yet, I would again recommend you to discuss with your doctor regarding rituximab or splenectomy as an option in terms of long term therapy.
Let me know the feedback of your child sir.
Also let me know if you have any more questions or concerns.
Wish you all the best.
Sincerely,
Dr Parth Desai
Note: Do you have more questions on diagnosis or treatment of blood disorders? Ask An Expert/ Specialist Now
Above answer was peer-reviewed by :
Dr. Raju A.T
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