Thank you very much and thank you for joining us tonight. So let's get started on immune mediated thrombocytopenia. OK, so first of all, what is IMTP?
So thrombocytopenia is the most common cause of spontaneous bleeding in dogs, and it's a rare condition to see in cats. We don't often see it in cats at all. It's caused by a decrease in circulating platelet numbers, and it can be as a result of a couple of different things which we list in a couple of slides.
So first of all, let's have a look at the anatomy and the physiology. So what are platelets? So platelets are small nuclear cell fragments that bud off from larger cells called megaarriocytes.
They're specialised large blood cells which originate in the bone marrow, that's where they're produced. And in a healthy blood vessel and with normal blood flow as well, platelets would not adhere to any surfaces, they just flow along the blood as normal, same as every other blood cell. They don't aggregate to each other and they just go along with all the other cells.
So if there's an injury or the patient has an accident and there's any injury to the vessel itself, the platelets start to ease, and the activation begins and that will just cause the platelets to start adhesing each of them. They will also get a, an adhesive layer on the outside of the platelet, which will, which will promote proteins to stick to the surface of the platelet. So that will just punch a load of the cells together and then that can go to the target, the damaged vessel and it can form that platelet plug.
And the main reason for that is just to form a plug over there, over the, the damaged area to stop any haemorrhage or any, any bleeding that might be occurring. So the key of all these receptors is that the adhesion interacts, that the interaction only takes place in the event of an injury if when if and when we need it. And it's just for the damage of any blood vessels.
So the platelets will then form the plug over the injury, and this is called primary coagulation. So with primary coagulation, before we go on to secondary, the only things involved with primary are your platelets and also your von Willebrand factor as well. All the rest, all your coagulation factors are involved with your secondary coagulation.
So secondary hemosta hemostasis is the activation of the coagulation factors which are there in your plasma. So it's defined as the formation of fibrine, which activated circular coagulation factors, specifically thrombin, that's the main one. So fibrin stabilises the primary platelet clot and just keeps it in place on that damaged vessel, particularly in larger blood vessels.
If the if the platelet plug is not quite big enough or it's not strong enough to stop any haemorrhage, then this fibrin will just keep that plug that plug in place so that all the other, the secondary coagulation factors can start to kick in and just stop that, that thrombo, the haemorrhage before it gets too severe. OK, so there's many, many different types of causes for thrombocytopenia. So the first one is decreased platelet function.
So if you have a disease of your bone marrow, your bone marrow will not be producing as many platelets as it should be. And that can be many different things such as viruses like parvovirus, FIV, FELV and also chemotherapy drugs as well. They will attack the, the bone marrow and will affect the production of your platelets along with other cell lines.
We also have leukaemia that might decrease platelet numbers due to the destruction of the bone marrow architecture. And increased platelet destruction. So immune-mediated thrombocytopenia is where the immune system will attack those platelets and actually destroy them.
You've also got your chemotherapy drugs again and non-steroidals, which is one that we don't often think about and we use very regularly in practise. So you've also got platelet loss or consumption. So you've got things like DIC disseminated intravascular coagulopathy.
So if you have DIC, your platelet consumption will be increased, so if you run a haematology. You will see that your platelet numbers are starting to go down and that's because your body is starting to consume those platelets and you will see the patients start to bleed out into different cavities, whether it be the abdomen, the thorax, the pleural space, can even be the brain. With DIC patients or patients with SAS, if they get any leakage of their vessels, which they quite often do, especially when the platelets are affected, they can have a little bleeding to the brain and you, you can quite often see signs like nystagmus or neurological signs, and that's just because it's starting to affect the central nervous system once the haemorrhage has started in the brain.
So many different reasons there. So you can also see an increased consumption with sepsis, vasculitis, splenic torsion, or just plain old haemorrhage as well if the patient is haemorrhaging maybe it's got a splenic mass there which is ruptured. So also splenic sequestration.
So this just basically means when the blood pools in the spleen, hypersplenism, so that's 90% of the circulating platelets become sequestrated in the spleen, and that can be caused by a severe hypothermia or certain drugs as well, such as ACP can cause splenic sequestration, but it wouldn't be enough to affect your platelet numbers. So you can also see it with tick-borne diseases, so Babeia canni, Ehrlichiosis or Rocky Mountain fever. Rocky Mountain fever is seen in the USA in certain parts.
So if your patient has been on holiday abroad anywhere, if they have a passport and you know, the owner travelling with them, then that's definitely one to screen for and just check the areas that they've they've been to if they have been to America. So it could also be secondary to other immune mediated diseases. So once you get one immune-mediated disease, your immune system can go a little bit crazy and it can kick off other other diseases as well.
So it can just start to destroy and attack other cells. So things like immune-mediated hemolytic anaemia or IMHA. So that's the most common concurrent disease after IMTP.
So if you're going to get another. Immune-mediated disease, it's quite likely IMHA, but it could also be things like immune-mediated polyarthritis or meningitis, many other things, but this is the most common. You'd also see it with drug reactions, so phenobarbitone, quite commonly used drug, and this has been shown to, if the patient has been on this drug for up to about 6 months, patients have been seen to develop signs of IMTP, and the signs will totally disappear once the drug stops.
So once you withdraw that drug, the IMTP disappears. And also live vaccines as well, live virus vaccines. It can affect your platelet numbers.
Also, the common one, neoplasia, lymphoma or hemangiosarcoma. Infection, so something as simple as a urinary tract infection, any type of infection can flare up your immune system and that can cause any of these immune-mediated diseases. Or it could also be idiopathic, so we don't know the cause.
It's just caused, it's just came on and there's no underlying condition, and that's all you've got just IMT pain. It's not secondary to anything. It's just idiopathic, meaning we don't know what's causing it.
OK, so when you have a patient with low platelet numbers, there's certain considerations that you need to bear in mind when you're nursing these patients. So they're susceptible to excessive bleeding. So jugular veinal puncture is an absolute no no.
If you have patients which are under on treatment, they've come in for maybe a follow up blood test just to see how they're getting on. You can check with your vet if they're happy for you to, To use the jugular, sometimes they are depending on the previous platelet counts and how the patient's been doing at home. But if we're suspecting IMTP in these patients and we don't know the platelet count up to now, always avoid the jugular sample, just avoid it altogether and go for a sofina or cephalic.
Any anything peripherally. Central venous catheters and epidurals are contraindicated just because of the risk of haemorrhage. If you place an epidural in these patients and it bleed, they bleed into the spinal cord, you're going to affect your central nervous system there and have detrimental effects potentially.
So we should wear harnesses for these patients, take off the neck collar, give that back to the owner if they're being admitted to the hospital and just have a loose harness on these patients. And the reason for that is there's two big jugular vessels right under the skin under the neck, on the neck. So if we've got a collar and we've got a dog who pulls on that lead, we don't, we just want to avoid anything on that neck to try and avoid any signs of haemorrhage appearing, so it can get really big hematomas there or it can bleed under the skin.
And when you shave the fur, you will start to see real haemorrhage from, from the jugular sample, the jugular vessels. So just avoid thinner around the neck. And care should be taken when you clip the fare as well.
So make sure you're really gentle. Even if you're really gentle with these patients, it will still bruise, but just be extra cautious when you're doing it and especially in delicate areas like the abdomen. If you're clipping for an abdominal ultrasound, you'll see that there's there'll probably be some spontaneous bruising there on the skin, but by the time you've finished, more will be there just from, just from the sake of clipping the abdomen.
And a pressure bandage should always be applied for 5 minutes after a peripheral venal puncture. So even though it is just peripheral, we tend to, for a normal IV cast, so we'll just place a small swab with some tape over the IV site, take it off a couple of minutes later, but with these we will use vet wrap and just wrap it in a larger area, just to make sure it's more diffuse and it's not just going to cause a load of constriction in one small area. And I tend to set my alarm on my phone for 5 minutes just to make sure you don't go leaving it on there for half an hour and get distracted with your next job.
OK, so platelet production, this is regulated by a total platelet mass rather than numbers. So your normal platelet count is 175 to 500,000 microliters or 175 to 500 times 10 of 9, which is easier, easier to say. So IMTP platelet count is often about 25.
Rodenticide toxicity platelet count is 50 to 75, and that's the same with lymphoma of the spleen as well. So you tend to see spontaneous bleeding with anything under 50, . 50 times 109.
But you will start seeing a lot more haemorrhage if it's 30 or lower, and I think it has to be around about 80 in order to do any samples of any organs. So if you need any fine needle aspirates via ultrasound, you need sort of the spleen, of the liver. I think it needs to be roughly it's around about 80, .
Just to make sure that you don't have any spontaneous bleeding, you don't want to go popping any needles into those organs and causing a massive haemorrhage. OK, so breed specifics. So they tend to affect middle aged female dogs, and there's two breeds which are overrepresented.
We've got the old English sheepdog and the cocker spaniel. So we tend to see lots of cocker spaniels with this. A greyhound is a non-clinical thrombocytopenia and their normal platelet count for greyhounds is 80 to 100.
Cavalier King Charles have an inherited thrombocytopenia, with around 50% being affected, 50% of cabbies. This is an autosomal recessive trait, and the platelets are often less than 50. And although the platelet number is decreased, the platelet mass remains the same, so they have larger platelets, so the actual mass, the amount of platelets there might be decreased, but the mass is the same because they're bigger and they work just as well.
So they're not clinically affected by these, by the thrombocytopenia. Totally normal in these patients. So clinical signs and findings, the little photo on the side, this patient didn't have any haemorrhage at all, and that was just caused by the clippers.
So you can see just some tication there, just from clipping that bit of there, and that was seconds after. After the clippers have been removed and then it carried on bleeding, later on once the IV was placed and once we'd irritated that part of the skin with the clippers, you could see it, it started off the haemorrhage and it just got worse and worse. So clinical signs.
So first of all, you might see spontaneous haemorrhage, so little bits of haemorrhage appearing on their own without necessarily knocking a limb. You might just part the there and you'll see bruising without anything even happening, petechiation or ecchymosis on the eyes, nose, the mucous membranes. You might, they might come in and they're lethargic, they're feeling under the weather.
They might be anorexic if they're not feeling too well. Weakness and collapse quite common to see, especially if other cell lines are affected as well. So sometimes it's not only your platelets, it could be your red blood cells as well if you have IMHA.
Hematuria because they're bleeding into their bladder. Gastrointestinal bleeding, Melena hematoshezia could be a sign of a GI bleed. And especially if you have dehydration in these patients, which if they're anorexic and they go off their food and their water, they quite often can become dehydrated, then they're more likely to have a GI bleed.
So we need to look out for them, make sure you've got no abdominal tension or pain there, which could be a sign, and also just check the faeces and get a really good history from the owner as well. So you might see pale mucous membranes if you have IMHA alongside. A tachycardia, that's just the body, the body's natural response to compensate for the lack of cells there.
And you might also hear a heart murmur, usually a grade 1 to 2, and that's just due to changes in the hemodynamics. So if you have a loss in the amount of circulating blood that you have, it will just, it can cause a heart murmur there just because of the, the change in the hemodynamics. OK, so thrombocytopenic patients can deteriorate rapidly and this is most common due to a GI bleed.
And that is we, we quite often see GI bleeds and the thrombocytopenia may go unnoticed for a little while with the owners and then it's only when they come in with this bleed that they collapse, they're weak, they're lethargic, and that's when they'll come in and we'll find that they're thrombocytopenic. So haemorrhage into the vital organs as well, as I mentioned earlier, into the brain or the lungs, they might get dyspnea, they might get signs of any central nervous signs, so they might have for any proprioceptive deficits if they have a haemorrhage in the brain or nystagmus is the most common one, and that's a central nystagmus, so it's going up and down rather than left to right, and that just means it's central so it's in that CNS, it's in the brain or the spinal cord. And that's, we've seen that quite a lot.
It could also be if they have IMTP it could be a clot that they've thrown, even though they have low platelets. They could have thrown a clot if those platelets have started to addese. They've thrown a clot into the brain and that's quite often, quite sad to see when you see them.
So patients should be hospitalised until the, the platelet count is above 50, ideally. And just briefly mention about Evans syndrome. So Evans syndrome is when you have IMTP and IMHA together.
So both of those conditions together cause Evans syndrome, and it's just caused basically by the immune system. Once one starts off, it will trigger other immune-mediated diseases and then the next most common one is IMHA. So this carries a poorer prognosis rather than if you have either or.
So if you have IMHA on its own or IMTP on its own, the prognosis is classed as good, but if you have both of them together, it carries a much poorer prognosis overall. OK, so how do we diagnose IMTP? So first of all, we want to do haematology and check your platelet count and all cell lines as well.
So your red blood cells, your white blood cells, check all of your different blood cells and just see what's going on there. You could only get a decrease in your platelets, but there could also be decreases in other cells as well. So when you're checking your platelets, a blood smear analysis is the most accurate to do in-house.
So you can have a little look and count the amount of platelets that you can physically see, whereas some of the in-house haematology machines might provide a false platelet count, and that's just because of the platelet clumping. So if the, if the platelets have been activated and they're starting to adhese to each other or other proteins, the machine will read it as a larger cell than what a platelet should be, and it will put it down and say a macro macrocyte, macrophage or whatever, . It might think it's a different site because there's a couple clump together and it will throw out an an inaccurate result.
So microscopy is much more accurate so you can actually see that's a clump, it's not a large cell and then you can count all of the others that are present there. So your bule mucosal bleeding time or BMBT, this will be delayed if you're thrombocytopenic. However, if you are thrombocytopenic on your haematology, you don't need to do a BMBT because if they are low, you know that it's going to be prolonged.
BMBT only checks for platelets, platelet numbers and platelet function. So the only things that would affect this are if your platelet number is low or if the function is affected in things such as von Willebrand's disease. So if your platelet numbers are low, there's no need to do a BMBT and it's actually contraindicated, you don't need to do one.
If your platelet count is normal, but you think the function might be, altered, like in von Willebrand's, then you would do a BMBT and that's perfectly fine. All the clo clotting factors will remain normal on the coagulation panel as IMTP only affects the platelet. So if you go on COAGs in a patient that's covered in petiation.
Chances are they will be normal because it only affects your primary coagulation cascade rather than your secondary. It doesn't affect any of your other coagulation factors at all. OK.
So we'd also do a full biochemistry, and this is just to check for signs of underlying disease. So we can do a full urinalysis as well, check for culture, check for signs of cystitis, is there any haemorrhage into the bladder? If there's any signs of infection, could this be what's caused, what's triggered the immune response?
We'd also do a saline agglutination test, and this is a test that we do for IMHA and that's the drop of blood, EDTA blood with saline on a microscope slide and If you have, if your patient is positive for IMHA, then you will get a, well, you're likely to get a positive saline glutination test, but if you don't get one, it doesn't rule it out. So they could still have IMHA, but it's not giving you a a positive saline agglutination. So to confirm IMHA, you need to do a Coombs test and this will come back as a yes or a no, positive or negative for IMHA.
You could also do a Bearman's faecal examination, and this is just for angiostrongylus pisorum, also known as lung worm, so you can pop the lentil sized piece on a microscope slide with a little drop of saline as well, and you can analyse that in-house or you can send it off for this faecal examination. Quite often you will see the little worms moving or you might see the eggs. It's intermittently shed, so you might see it on one sample and might not see it on the next, but it's worth doing and it's quite interesting to see if you can see any of the little worms under the microscope in-house.
It's an interesting one to do. And also it's useful to send off a serology for your tick-borne diseases as well, or an occult diophylars. As we mentioned earlier, depending where the patient has been, if we're down south or if we live in grassy or foresty areas where they might have ticks, it's definitely worth doing even if they haven't been abroad.
If they have been abroad, definitely worth doing because you can get many, many different things such as Leishman's, Leishmania. Many different, different diseases that you can pick up from different countries. OK, so splenomegaly is often seen on ultrasound or on radiography and even if when you're palpating the abdomen, the spleen feels normal, it's quite often picked up in these patients on the ultrasound.
The diagnosis is one of exclusion, so you need to rule out all of the other conditions that might be causing a low platelet count, check what drugs the patient's on, could the drugs be affecting it? Have they been vaccinated recently? Are they are receiving chemotherapy?
Many different things in that list that we mentioned earlier, you need to exclude all of them and if you haven't picked up any underlying condition, then the chances are you have IMHA sorry IMTP. So your blood work, body imaging, infectious disease panel, and your bone marrow evaluation is necessary to rule out other causes of thrombocytopenia. And even though doing a bone marrow aspirate or biopsy might seem really invasive on a patient who you can't even put a neck collar on.
The risk of bleeding is minimal for these procedures, and we do it quite often for if IMTP is suspected just to see what's going on with that bone marrow, see what's going on there if it's diseased or just check what's happening with the cells and why it isn't producing or may not be producing the amount of platelets that it should be. Float cytometry, this can be used to detect platelet surface associated immunoglobulin, bit of a mouthful, although it often produces a low false, sorry, a low false positive result. So it's hit and miss whether you want to do that one.
OK, so how do we treat IMTP? So treatment of the underlying cause, depends on what that underlying cause is and supportive care and also immunosuppression. So we need to suppress that immune system so that it doesn't attack any more of the cell lines.
So if IMCP is suspected and your platelet count is low on your haematology, if you've got a fairly asymptomatic dog with spontaneous bleeding, then you could trial immunosuppressive corticosteroids, at a dose of 1 to 2 milligrammes per kilo. So 1 to 2 mg per keg twice a day is an immunosuppressive dose. If you have them on, say, for example, 0.5 mg per kg, it won't suppress the immune system and it won't treat this condition.
It needs to be high, 1 to 2 meg per kg twice a day. You'd usually see a response within 2 to 7 days, ideally. And so you've got two different types of corticosteroids, you've got dexamethasone and you've got prednisolone.
They're equally as effective at treating IMTP. Only dexamethasone is slightly more ulcerogenic. So, if you put them on dexamethasone, the chance of them developing a gastric ulcer is a lot higher than if your patient was on prednisolone.
And if this patient were to develop a GI ulcer, then that could be catastrophic because they have IMTP and they could just bleed out internally. For that reason, prednisolone is the preferred corticosteroid of choice for this condition. And just to be certain, we tend to put them on a H2 antihistamine or a gastroprotectant such as omeprazole, ranitidine, tacralfate, and epsin alongside the steroids, and that just prevents a GI ulcer as best as we can.
So you can see your little purple platelets over to the right then. So more treatment options. So we've got Vincristine, which is a chemotherapy drug, and this causes early platelet release from the bone marrow.
So these platelets that are released are not fully functional, so the patient could still have further bleeding before the platelet count increases, but it's really good, a really good drug to have on board just to increase that platelet, that platelet count. It improves responses have been, have been documented in dogs who receive vincristine compared to prednisolone on their own. It should be administered to induce remission, but shouldn't be used as a maintenance drug.
Cyclophosphamide can be, sorry, vincristine can be used for a maintenance drug. It's cyclophosphamide that can't, and that's because it can cause sterile cystitis. OK, so we might need to do a blood transfusion here depending whether our red blood cells are affected or our other cell lines.
And we also need to know why, when would we do it for platelets and when wouldn't we? So first of all, it needs to be a fresh whole blood sample. Fresh whole blood will have platelets present, but you need to transfuse this within 6 hours of taking it from the donor patient.
So fresh whole blood will carry many different things such as your red blood cells, white blood cells, plasma, platelets, your anticoagulants, and your coagulation factors. And you might use it for acute blood loss or coagulopathies such as your thrombocytopenia. So fresh whole blood, the issue with freshhold blood is it expands your intravascular volume.
So if you have a normal volemic patient to Isn't hypovolemic at all. There's no losses there or any deficits, and you go given whole blood, you can overinfuse these patients quite quickly. So you need to be very careful.
The chances of of transfusing any effective platelets that are actually still functional is low because they're damaged really quickly, very easily, and if they sat in the fridge for more than 6 hours, the platelet count will be reduced. And really after 6 hours, we wouldn't transfuse if platelets is what we needed, because even though it says after 72 hours of refrigeration, platelet function is completely lost, it would have such a small amount after 6 hours that it wouldn't be useful for this patient. And if anything, you're going to cause more harm because of the over infusion risks.
So you can use, due to the difficulty, the transfusion of whole blood platelet rich plasma or platelets, rarely results in normalisation of the platelet count or even an increase to a safe level. So you're infusing the plasma, all of the other cells as well, as well as those platelets which may not be doing anything, and they're the ones that you need. So, You would only really do a threshold blood transfusion if your patient had a decrease in the other cell lines as well.
And if you needed to increase your oxygen carrying capacity. So if you have IMHA alongside your red blood cells are really low, you're anaemic, then you can give this product or you can give red blood cells to them, rather than whole blood, you can give packed packed cells. But yeah, for platelets, it's quite difficult, a difficult one to transfuse because they're so friable.
Remission. So fail failure to reduce remission is often due to insufficient drug dosages. So have you put this patient on steroids and it's not a high enough dose?
Have you given a 0.5 mg per kg of the steroids rather than the 1 to 2 mg per kilogrammes that they need twice a day? Also, have you put them on a long enough dose of the drug?
Have you given it for 2 months or have you given it for 2 weeks and they haven't gone into remission, it hasn't fixed the patient because you need a much longer dose, longer duration, and also no second drug. I added alongside the corticosteroids, so there's a much better outcome rate if you have two immunosuppressives here. So if you have your prednisolone along with your vincristine, for example, that has a much better outcome for these patients.
OK, so how do we monitor these patients? So platelet counts should be monitored regularly and as you can see there's a jugular sample being done on the right. That can be done, as I said earlier, depending on how the platelet counts are looking from the previous sample.
And also depending on the history from the owner, has there been any signs of spontaneous bleeding? How is the patient seeming if there's signs of relapse, then you might want you to avoid the jugular samples and treat it as if it's just coming in from scratch, brand new patient. Otherwise, if they seem to be doing well on the treatment, you might be OK to go for a jugular sample.
But again, that's just up to your vet and just always be cautious and always ask in an IMTP patient whether you can go jugular or not. Once it's maintaining within the normal limits, prednisolone can be reduced by 25%. The dose can then be reduced further, but it's important to do this over 3 to 6 months.
Don't look at the patients and think, oh, it's doing great. Let's reduce it down for 2 weeks and then 2 weeks again at a slightly lower dose again. You need to be slow with these patients and do it over 3 to 6 months just to make sure that you don't tip them back into IMTP.
Weaning too quickly can cause a sudden relapse. Relapse is unpredictable and it's relatively common as well. We see it quite often that you'll have a patient who looks really good and then the next day you come in and they look dreadful and they've gone into remission for one reason or another, or they've gone home.
And the owners have thought, oh, he looks great. I've reduced down the prednisolone or have taken them off. Or sometimes a GP might alter the dose slightly, and if they're not, if they haven't seen the full history that the specialist might have done, then there could be too many cooks involved and they might alter the dose too quickly and this patient might go into relapse.
A second immunosuppressive should be introduced if a relapse occurs. And what other drugs are available? Which of the ones can we use?
So in a dog, you can use azathioprine. And the dosage written there 2.2 milligrammes per kilo and that's pay hours once a day.
This is good for maintaining remission, but it's not good to induce remission. So it's a good drug to keep them on once once the remission has started. You can also use cyclosporin 3 to 7 milligrammes per kilo twice a day, or mycophenolate, 10 to 15 milligrammes per kilo twice a day, and there's also cyclophosphamide as well.
200 milligrammes per metre squared. Sometimes they can work out per metre squared rather than per kilo because it's more accurate. There's different calculations that you can do to use to calculate the 1 metre square of a patient, and they quite often use that with chemotherapy drugs just to make sure it's really, really accurate.
And that's weekly divided over 3 to 4 days. In cats, we would use cyclosporin and that's 4 to 6 milligrammes per kilo, so it's a different dose for cats as it is for dogs, and that's twice a day. OK, so we've got IMTP in cats.
So as I said earlier, this is quite rare in cats, we don't often see it. If you have seen one, great. I don't think I have actually ever seen one in a cat so far.
Clinical presentation is different to that of a dog, and cats have a chronic thrombocytopenia, so they'll have this underlying for a long time and you might not pick up on it. The owner might not notice, they might not show any signs, and then you come in unwell for another reason, or maybe they've just suddenly gone lethargic or starting to feel under the weather and you picked up a thrombocytopenia on their bloods. So they don't get spontaneous bleeding like dogs do.
They don't always show other signs, and their platelet count doesn't increase markedly with treatment either. So quite often we don't treat cats. So we will see a thrombocytopenia present, but we don't often give any drugs to treat him because it doesn't really make that much difference for these guys.
So the thrombocytop the cytopeniaas may resolve alone and then 2 weeks later you might do another blood sample and there might be another cell line that's decreased. So it could be red blood cells one week, white blood cells the next week. It could be anything, lymphocytes, and then it could be back to thrombocytes again.
So they're very, very hit and miss cats, so it could be one cell line, it could be multiple, and then they can chop and change as well. Treatments may also be more problematic because if they don't get any spontaneous bleeding or necessarily any symptoms, what exactly are we treating them for? And it can't be monitored by a platelet count alone due to the other cytopenias which occur, so you might treat the cytopia, the thrombocytopenia, and then the other cell line disappears and it's more problematic to go trying to Treat all of these different cell lines that might be going down when the patient is actually perfectly well, showing no signs, no bleeding at all, and they're just getting on with it because it's chronic and it's been there for a good, a little while.
So yeah, it's a bit of a funny one in cats, but we don't tend to treat it, and we don't tend to see it very often either, whether that's because it's not as common or whether that's because they hide it really well, who knows with cats. So the prognosis for IMTP? So the patient may require lifelong treatment of immunosuppressive therapy.
And the prognosis of IMTP is good, providing it's on its own. So if we have IMTP and IMHA, then the prognosis is much poorer and these patients are a lot more sick if both are present. But yeah, as long as you have good owner compliance who's willing to have them on steroids lifelong, one of the things I tend to find with steroids is the patient will, the owner will be really happy to medicate these for lifelong purposes.
The side effects of the disease they can cope with the side effects of the steroids, they can't. So they'll be drinking more, urinating more, maybe they'll wee in the house during the night, which they've never done. The owners pick up on these and even though you've warned them this might happen and it's simply just a side effect of the steroids.
They seem to worry a lot more about these side effects, and we've had patients being euthanized because the owner thinks that this patient must be in distress if they're getting up and urinating during the night. And that's one thing that you really, really need to educate these owners. This will happen, but the patient is perfectly fine and we'll wean down on the steroids as and when we can, if we can.
And they'll be on them lifelong, so it's, it's very important to educate your owners. OK, and that's the end of the presentation. Thank you very much for listening.
Sorry, I muted myself twice there, that's why I think. Thank you. I was like, why is no one here me?
Ah, there we go. Thank you very much for that Sophie, that was fantastic and er some greater advice there and some very clear. Elements for what what steps they should take, so thank you.
So just give you a few minutes just to have a think about any questions because Sophie's finished in good time. What I want to do is trying to say thank you to JHP recruitment for sponsoring our nurse stream. We really appreciate their continued support to help us bring such fantastic webinars such as this.
So, is that your, dog there, Sophie, being well behaved with the biscuit in its nose? That's my dad's two dogs, yeah, Minnie and Ruby. He's got some, he's done some good training.
Cos I know my, my lab would not do that, have a bisque on its nose for that long. So yeah, so I, I'm not actually veterinary trained myself, so please do, if you've got any questions, please do put them in and, we will pose them to, Sophie. Also just a reminder at the end of this webinar, there will be a short questionnaire that will pop up as well.
So please do take your time to complete that questionnaire. Because it really helps us give the feedback, to the presenters, but also help develop our, programme going forward as well. Well, it looks like you're being let off here, Sophie.
Oh I think you must have covered all the areas and that no one's got any questions for you, so, you can go and enjoy the rest of your evening and I hope your little one doesn't keep you awake too much tonight. No, hopefully, thank you very much. No, well, thank you and thank you to you, Sophie.
Thank you to everyone for attending and also thank you to Lewis for being on hand to assist with any technical queries. Enjoy the rest of your evening. Good night.
