Is a cure for IMHA near?

Veterinarians are making progress in researching the genetic and environmental factors putting dogs at risk

The image of a straight line neatly sums up the frustration of treating dogs afflicted with immune-mediated hemolytic anemia (IMHA), according to Andrew Mackin, BVMS, DVSc, FANZCVSc, DACVIM, professor and head of the Department of Clinical Sciences at Mississippi State University College of Veterinary Medicine. Dr. Mackin is a member of the American College of Veterinary Internal Medicine’s (ACVIM) Small Animal Internal Medicine consensus committee, which will present recommendations for immunosuppressive therapy for treating IMHA at the ACVIM 2018 Forum this month.

A straight line is how a graph charting average mortality from the disease as presented in journal articles over the past four decades would look, said Mackin. The average mortality rate for dogs afflicted with IMHA within three to six months of diagnosis and treatment, has stubbornly hovered at about 50 percent, he said, even as veterinary medicine has advanced and outcomes for dogs with many other diseases have dramatically improved.

“Everything we do is chipping away, chipping away,” Mackin said. “We’re getting a little bit better and a little bit better.”

Keith Richter, DVM, DACVIM, chief applied science officer for Ethos Veterinary Health, which runs a network of specialty veterinary hospitals, also thinks that treatment is gradually, but perceptibly, improving.

“Our critical care skills are better; our transfusion skills are better,” said Dr. Richter.

The most common autoimmune disease

IMHA is the most common immune-mediated disease to affect dogs, and a busy specialty or emergency veterinary practice may see dozens of cases a year, said Richter.

Yet although it’s the most common autoimmune disease, it is still a rare condition, said James W. Swann, VetMB, DACVIM, DECVIM, MRCVS, who is researching the effect of systemic inflammatory disease on hematopoiesis at the University of Oxford’s Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences.

At large university-affiliated animal hospitals, dogs with IMHA represent about 1 percent of all dogs brought in for treatment, but that number may be lower for general veterinary practices. He recently worked on a project analyzing medical notes from 240,000 visits at veterinary practices in the U.K., which found that about 120 dogs, or 0.05 percent, had IMHA.

“These figures were difficult to verify, which is why this data has never been published, because we were not sure that all these dogs definitely had IMHA,” said Dr. Swann, who is also serving on the ACVIM consensus committee.

The precise interplay of genetics and environmental triggers that cause some dogs to get the disease is still not completely understood, according to IMHA experts.

Genetics likely play a role in the development of IMHA because certain breeds are more likely to be affected than others, said Richter. Cocker spaniels and springer spaniels are among the breeds commonly affected. In fact, the prototypical IMHA patient would be is a “middle-aged, female cocker spaniel,”
he said.

But one of the many mysteries of IMHA is that breeds commonly affected vary geographically, said Mackin. For example, Old English sheepdogs are known in Australia as a breed that commonly develops IMHA, but in Mississippi, where Mackin resides, dachshunds are commonly affected.

“Every time we think we find a genetic trait that puts a dog at risk, another study doesn’t confirm it. We know there’s a genetic link, but we haven’t put our finger on it,” he said.

Steven Friedenberg, DVM, Ph.D., DACVECC, an assistant professor of small animal emergency and critical care medicine and genetics at the University of Minnesota College of Veterinary Medicine, is hoping to shed some light on the genetic mutations associated with IMHA. He and his research team published a study in 2015 demonstrating an association between a variant of the DLA-79 gene and four immune-mediated diseases in dogs, including IMHA. He’s now conducting a study comparing the genes of English cocker spaniels and clumber spaniels that develop IMHA with the genes of healthy English cocker spaniels and clumber spaniels, hoping to find genetic mutations associated with the disease.

According to Dr. Friedenberg, preliminary data from the two spaniel studies indicates that genetic predisposition to IMHA may be complex, instead of one “slam dunk” genetic mutation that causes the disorder.

Friedenberg is also starting a study to look at gene pathways that are differentially regulated in dogs with IMHA in hopes that it will help veterinarians better understand the IMHA disease process and possibly lead to more effective therapies.

“This study could potentially get us some quick answers in terms of what’s going on and explore the pathogenesis in a new way,” he said.

More research needed on triggers

More research is needed to understand the environmental factors that may trigger IMHA, said Mackin. Sometimes, the trigger is clear, such as reaction to a drug like a sulfonamide, but in many other cases, the cause is unknown or merely suspected, he added. Cancer, tick-borne infections like babeisosis, and bee stings all are associated with IMHA—but association doesn’t prove causality, he said.

The limited amount of data on trigger factors makes it challenging to pinpoint them, noted Unity Jeffery, VetMB, Ph.D., DACVP, an assistant professor at Texas A&M University College of Veterinary Medicine and Biomedical Sciences. The many breeds of dogs that develop IMHA, combined with seasonal variations in disease frequency, point to environmental factors,
Dr. Jeffery said, but it’s still not clear what they may be exactly.

“Identifying these triggers is increasingly becoming a focus of veterinary research, but the limited availability of large epidemiological databases in veterinary medicine makes the discovery of environmental practices challenging,” said Jeffery.

At the June ACVIM Forum, anther consensus committee will review evidence for IMHA trigger factors. It won’t provide any groundbreaking information on triggers, “but will give an assessment on what has been published so far,” Swann said.

A complex soup

Once a dog is diagnosed with IMHA, the complexity of the disease makes it much more challenging to treat than a disease with a uniform presentation and one standardized treatment, such as transmissible venal tumors, said Mackin.

“IMHA is a complex soup of many different presentations,” he said. “Some versions destroy red blood cells by popping them and others eat the red blood cells; some dogs have the disease affecting their platelets and others don’t. You can’t expect one cookie cutter treatment to work.”

The foundation of treatment is steroids often combined with one or more immunosuppressant drugs such as cyclosporine, azathioprine, or mycophenolate.

Because blood clots frequently are a complication of IMHA and thrombosis is associated with higher mortality, aspirin, heparin, or clopidogrel also are often used to reduce the risk of blood clots, said Mackin.

However, there’s little evidence on which drug or combination of drugs is most effective, said Richter.

The upcoming consensus statement will provide recommendations for using immunosuppressants, said Mackin, adding that tailoring treatment to individual dogs is crucial and that more therapeutic drug monitoring tools are needed.

“Dogs have narrow therapeutic windows,” he said. “The gaps between effective, ineffective, and dangerous drug doses are really narrow.”

One such tool is an assay that was developed at the Pharmacodynamic Laboratory at Mississippi State University College of Veterinary Medicine
that can help gauge the immunosuppression activity of cyclosporine and provide dosage guidance to veterinarians who submit blood samples of dogs they are treating. Similar assays likely will be available soon for other drugs, said Mackin.

Swann is working on a study analyzing blood samples from dogs with IMHA to measure biomarkers such as pro- and anti-inflammatory proteins and the expression of pro- and anti-inflammatory genes that might be able to be used to predict how dogs will respond to treatment, as well as whether they are likely to develop serious side effects.

“Our hypothesis is based on our opinion that there already are effective immunosuppressive drugs available, but that treatment should be individualized for each dog to control the disease while minimizing side effects,” said Swann.

They will study whether the biomarkers they measure correlate with treatment outcomes, he added.

Plasma exchange shows promise

One promising new treatment is plasmapherisis, also known as therapeutic plasma exchange.

Results from trials at Ethos hospitals have been promising, said Richter.

“We’ve had success with a few dogs that were dying and were not responsive to even aggressive immunotherapy,” he said.

Mackin said that while he, too, is cautiously optimistic that plasmapherisis may become another effective treatment option, it’s available only at a few facilities and is expensive and labor intensive.

“We’ll find the answer”

The experts agree that it’s frustrating that not more progress has been made in preventing and treating IMHA in dogs. However, it’s being made slowly, they said, and the upcoming consensus statements on trigger factors and the use of immunosuppressants will provide valuable guidance to veterinarians treating dogs with this very serious and complicated disease.

“We are doing a much better job of keeping dogs going long term without intolerable side effects,” said Mackin, adding that he is hopeful that someday IMHA might be a easily diagnosed and effectively treated disease.

“I firmly believe that some time in the future we are going to look back at this and recognize that this is a simple disease with a fairly simple diagnosis and a simple treatment,” he said. “One of these days we are definitely going to find the answer.”

“I firmly believe that some time in the future we are going to look back at this and recognize that this is a simple disease with a simple diagnosis and a simple treatment. One of these days we are going to find the answer.”—Andrew Mackin, BVMS, DVSc, FANZCVSc, DACVIM, professor and head of the Department of Clinical Sciences at Mississippi State University College of Veterinary Medicine

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67 thoughts on “Is a cure for IMHA near?

  1. It’s good to know people are interested in finding ways to better manage this disease. My standard poodle was diagnosed at three years old in Feb 2018
    My biggest struggle seems to be managing the side effects of prednisolone and azathioprine he is also on Zantac. His diesel are tapering off but still diarrhoea on and off is a major factor. Thank you

    1. Hi Mary – I know this post is almost a year but thought I might share my story…. I have a dog that was over vaccinated, 13 vaccines in 6 days on top of a spay in the same time frame. This has caused her to get immune mediated polyarthropathy. She is currently on prednisone and aziathioprine…. I worked really hard for a year to get her on a lower dose of steroids. Finally at 5mg pred every other day and 10mg aziathioprine every other day. The only way I was able to get her to this point was through feeding a raw diet and a naturopath vet. Her name is Dr. Angela Casey in North Phx. You may want to check her out. Dr Casey has put her on Chinese herbs that have gotten her side effects way down and given the ability to lower all the steroids! The goal is to get her off the meds completely. I know you have a bit of a different situation but I hope this helps point you in a good direction if you haven’t already gotten there. Wishing you and your poodle all the best!

      1. Hi Tanya,

        I just came across your comment and was wondering if you could tell me the name of the Chinese herbs you give to your dog? Our dog was diagnosed with IMHA in February and a naturopath vet here in LA prescribed Gui Pi Tang. Is it this one you provide to your dog? So far we don’t see any progress with this herb so the one you got might be more effective. I’d really appreciate your advice! Thank you!

  2. My 6 yr old Irish Setter was diagnosed with IMHA in April 2018. We have been battling it ever since–4 months later, she haa improved, but not in the normal range on her CBCs yet. She just developed a raging case of Demodex that my vet and I assume developed because she has been on Prednison and Azathioprine. It’s a battle, but she’s a warrior–we’ll keep fighting. I hope one day soon a cause and cure will be found.

  3. I’ve had 2 back-to-back dogs that have contracted IMHA and both where Corgis. My first Corgi was 11 years old and contracted it in November of 2005. Despite treatment, she passed a clot and died a month later.

    We got another Corgi in 2006 and she contracted it around 2009. She was young enough to fight it off but because she was prescribed prednisone as part of the treatment, the side effect of it deteriorated her joints and she eventually couldn’t walk properly. We effectively had to carry her around for the rest of her life which ended last Saturday, August 25, 2018.

    I truly hope they can finally find a cure for this horrible disease and as pointed out, I think any dog is vulnerable.

  4. Very informative article. It’s been tough to find good and current information on IMHA. My Jack Russell Terrier (female, 6.5 years old) was diagnosed with IMHA last week, two days after a teeth cleaning. After her PCV went down to 9, she had a transfusion which raised it to 18 where it has hovered for 3 days. She’s on Prednisone and Cyclosporine. I’m hopeful she’ll survive long enough for it to be effective but really don’t know what to expect long term.

    1. I almost lost my dog to IMHA thee years ago. He had two blood transfusion at our local vet clinic but was still declining. I rushed him to a Vet Hospital 50 miles away and they ran all kinds of tests to find out what caused the IMHA. The first Vet told me the tests were a waste of money but I wanted to try since he was always healthy. They gave him a different type of transfusion and kept him for five days. They couldn’t get him to eat and wasn’t doing well. We decided to bring him home and try on our own. They sent us home with 4 different medications to give him. Within two months, we had our old dog back. He was doing really well, so our local Vet wanted to cut the dose of Cyclosporine from twice to once daily. However, he relapsed and we started back up on the two. It was a long battle and well worth it. I know there are dangers with this drug but it does make a big difference. I also found the Cyclosporine online for $60 for a months supply.

    2. Hi how is she doing on cyclosporine. my bella is on prednisone ever other day and vet nw wants her on cyclosporine. Im so nermouse giving her this new drug. have you done blood work since your dog is on this.

  5. My 19 month old black lab from South Carolina was diagnosed and we had to put her down that same day. We took her to the vet on Wednesday and she was gone by Sunday. She had 3 blood transfusions within 5 days and by the last one early Sunday morning, her blood cells were attacking faster then the transfusions coming into her. She was already so weak, she never would of made it through any chemo drugs. I couldn’t do that to my baby. So we made the hardest decision to put her down. She was our first pet. We need to find faster testing, so no one has to go through this too. It’s heart breaking. She was only 19 months old, we thought we would have her for at least 10 years.

    1. Yesterday my golden retriever collie mix 6 years old was diagnosed with ihma and her onset of symptoms was so quick and so severe she was suffocating we made the decision to euthanize. I had never heard of this and looking back at all her behavior and living life I am wondering if imha was also evident in brain development…She would sometimes lay with her head pressed against a wall. Her behaviors we sometimes odd but endearing although she also had a fight or flight reaction that was not warranted. I am now understand that this was all she had to express certain reactive symptoms. Reading father in the net tells me this might have been a sign of brain tumor or other neurological disease…Pretty was a rescue from the shelter who was still lactating when her pups were taken and She was abandoned. Writing this is all I can do for her now. She was my best friend. How can I help other dogs and owners?

  6. I had a 8 month old Mastiff that we had to put down after he was diagnosed with IMHA.
    He got sick out of no where but was in the hospital for about a week then came home with a lot of medication. Unfortunately July 3rd we had to rush him back to hospital and we had to make the decision on Huly 4th to put him to aleep.

    1. Last year my Bullmastiff, Mia, was diagnosed with kidney disease and IMHA as a secondary condition. She has survived this long, but now has an abscess. She isn’t even 3 years old yet. I know every case is different, but does anyone in here have a dog that has lasted years with IMHA? Mia is on prednisone and Aziathioprine. Any advice on how to keep her from getting infections?

  7. My10yr old skily was recently hospitalized for 7 days and diagnosed w IMHA. He got sick out of nowhere with vomiting first and then came the diarrhea.His RBC count was at 23 and when released from hospital it was at 27, and no more vomiting or diarrhea. My concern thou is that his RBC still seems low.

  8. My dog maple, a bluetick coonhound was diagnosed with this nasty disease. She had 2 transfusions, this disease ravaged her, I had to put her down.

    1. IMHA is a terrifying disease. My Cavalier King Charles was given a 50/50 shot survive the weekend. He lived 18 months with IMHA until the meds stopped working. Every single time we tried to wean him off them he relapsed. Those 18 months of caring for him were the hardest of my life. He had a good quality of life most of that time however I knew the disease was there, waiting to kill my fragile, sweet boy. IMHA is brutal. It is merciless. I hate it so much. As a last ditch effort we took him to UC Davis. They had no answer. Our hail mary pass was IVIG and that didn’t work either. Putting him down crushed me. We all fought so hard. I love you Pip.

      1. I am going through this with my dear Cali girl. At only 3 years old, she was diagnosed with IMHA. I even work in the veterinary field, and am going through the same challenges you had. My heart breaks for you, and as I watch my baby, I hold back my tears. Thank you

        1. I feel for you Gina. The past month we’ve been going through this with our 12 year old Rat Terrier male. Bandit is being treated with Prednisone 20mg for IMHA. He was his usual energetic self last month, then the next day not at all himself. Gave him a day to rest in case it was just old age, the next morning saw the vet. He was treated for an infected anal gland, put on antibiotic and came home. He kept getting worse and we couldn’t get him to eat with the pill, so I took him in that Monday for a 7day dose shot. The next day he went back because he was coughing. Doc took x rays and more blood, and diagnosed him with IMHA. His blood production was down to 17, after the first week of steroid he got up to 28, now is holding steady at 36 % on the low end of normal. He lost weight, and was/is bony, and his poor little head is so sunken in above his eyes. It is so hard to see him lose his personality and be constantly hungry. Best wishes to everyone for better health and a cure for our fur babies.

      2. Heather, our dog was just diagnosed with IMHA. As a last ditch effort, we just took her to UC Davis today, and we are hoping against hope that she’ll survive this. She’s only 4 1/2 year old (half German Shepherd and half Airedale terrier). It was devastating news, and I’ve been reading as much as I can about this disease. Just before taking her to UC Davis, we were heartbroken about the thought of having to put her to sleep….but then a glimmer of hope when we were told she work up today a little perkier and alert. So we rushed her to UC Davis. Like you, we are also all fighting this…..

      3. We’ve been fighting this with our 10&1/2 year old Malti-poo for 6 weeks now… after the first transfusion she rallied really well but has slowly declined and it’s becoming apparent decisions must be made. We have no idea what brought it on. She was fine on a Thursday, sick on Monday morning, in the hospital Sunday with this diagnosis… I guess, sometimes, it just happens with no real underlying cause… Se also have her full-sister/litter-mate… we’re watching her closely.
        It’s hearbreaking……

  9. This is an interesting article. I know in the hospital I work at, we see quite a few IMHA patients of many different breeds, so we’ll definitely look into the genetic testing study being run at University of Minnesota. Great info!

  10. Our 9 yr old cocker spaniel was diagnosed with imha on Monday. She had a blood transfusion on Monday which raised her pv from 10_25. She’s on steroids. We’re hoping that she’ll eventually start remake her own blood cells while she’ll have to take it easy we’re trying to be positive that she’ll make a recovery in order to lead a happy life for the reminder of her time.

  11. I have no more time. My 18 mo samoyed succumbed to sterile meningitus, then imha plus itp, then switching from dexamethasone & leflunomide to prednisone and mycofenolate, then they said she had a disease of the spine and brain stem. Then she would die from stopping breathing. Really?
    We are in 2018 guys! 8,000 later not to mention the suffrage plus interns ignoring my calls and what i had to say about her symptoms? In and out of er and neurologist that was so overworked. It is simple. I know. I got her at 8 wks old. Symptoms started then. Itching, facial swelling signs if impa then. That was at 8 mos. RIGHT AFTER PUPPY VACCINATIONS. THERE IS A REAL-POSSIBLE TRIGGER! HMMMMM. ALSO AFTER HER HEAT BOTH IST AND 2ND TIME. HELP! I GAVE UP MY LIFE FOR THIS DOG FOR 1.5 YRS. WATCHING TALKING TO 3-4 DIFF VETS. VRCC AN ER AND CLOSE ONLY BOARD CERTIFIED NEURO. POURING OVER SCIENTIFIC DATA. THE COMMUNITY NEEDS YOUR HELP. I CANNOT FAITHFULLY WATCH ANOTHER VERY SMART samoyed begging me telling me that mom, these drugs are not working and an intern responding to me saying all owners are experiencing the same thing, lethargy, distant etc. NO! She was dyeing slowly and losing her footing, and taking 3 steps at 2 and 4 AM at a time, looking for a place to die in the yard until i realized it was the meningitis coming back not that she substantiated yet another immune mediated disease of the spianalcord and brain stem in which she now had paralysis on all four legs, what? This was a healthy 8 wk old when she came home with me? Symptims start at 8 mos, dead at 1.5 years, heat and vaccine induced triggers? Please re look at your data. Both parent no problems.

  12. My 20 month old 6 lb. Maltese was diagnosed last Thursday and has been hospitalized since, She has had 5 blood transfusions in 5 days. Today she seemed more alert than she was last week, but they have told us it is an up and down disease. We are praying that her numbers stabilize and she can come home. Such a crazy out of nowhere disease…

  13. There are many causes of IMHA including vaccines, tick diseases, drugs, predisposition, hormones (females more likely to get it) & poisons. Reading the article, I am shocked at the figures for survival rates, which in my experience are total rubbish when the correct treatment protocol is used – no cure in this article either. I’m sorry to say vets are often ignorant, closed minded & slow to act. I am so sorry for all the owners who have lost their precious pups. For support from fellow IMHA owners, go to w

    1. Hi Sheena, your message is a few years old but I thought I’d try a reply to you anyway. I just found this site and tried to post a comment but can’t seem to. I wanted to let others know about I found them early in my dogs diagnosis and they were an immense help with a wealth of information for all of us that are flying blind with this disease. I think my dog may have gotten IMHA from an allergy pill prescribed by my vet.. I’m told any dog that survives this should never get shots again. Even my dog with focal seizures can’t have shots anymore so shots definitely can cause problems obviously.
      My dog that has IMHA was on high dose prednisone for 4 months along with antibiotics and ameprisole (an antacid). He had an adverse reaction to ameprisole causing severe diarrhea with bleeding. He’s now on Pepcid Ac. He’s also been on sucralfate all along. Whenever we take him off the antibiotic he gets diarrhea. He’s been on a probiotic all along too. He began losing red blood cells around the 4 month mark and we got sent to a specialist that increased the sucralfate because she thought he was losing blood from a bleeding ulcer caused by the prednisone. She also put him on gabapentin for pain as he was constantly trembling and added atopica to the prednisone but began decreasing the prednisone. She said she usually begins to taper prednisone while adding on atopica at the one month period because prednisone causes too many other issues. Because of prednisone he’s alive but now has calcinosis cutis on his tongue. He’s on half of his original dose of prednisone now and his tongue is slowly healing and his red blood cell count has just crossed over into the low normal zone. He still has very little energy but can climb the five steps on the back deck sometimes now and has jumped up on the bed which has a bench first to get there two times recently. Otherwise he still needs to be carried up the steps or onto the bed or sofa and into the car.His liver is very swollen which is causing his abdomen to be very swollen. Lots of hair loss and extremely dry skin, flaking everywhere. So many sad stories on here with nothing new since 2019. Hopefully the treatment has improved since then and my little guy will be ok. I know even if he recovers there’s a chance of relapse but at least my vet will listen to me right away instead of saying his symptoms were behavioural.

  14. My dog Lucy was diagnosed with IMHA a year ago this very day. I am so greatful that my husband and I got her to our vet in time to save her life. I love her dearly, she is like my child. On that same day we also found out that she has lyme disease. She was put on Atopica and high doses of Prednisone, it was awful watching her go through all that. 11 months she was on these meds. It was hard financially and emotionally. We were paying over $600.00 a month for her medications and that’s not including vet visits weekly/ monthly. In the spa. Of this year she had a rough road, her lyme disease made her unable to walk, we had to carry our 90 pound dog up and down the stairs to use the bathroom, she had several bladder infections, skin discoloring from the atop a, lost of fur and a bit of kidney damage from the prednisone. Now that she is off all of these medications we are now dealing with demodectic mange. This poor girl can’t catch a break. I’m so scared the Imha will come back

  15. Our 10 year old female cocker spaniel was diagnosed with IMHA and IMTP on Nov 5. She was started on pred and Atopica. Happy to say we started weaning 4 weeks ago. It was a horrible first 2 weeks! Keep up the research.

  16. I lost my 9 year old sweet Fred to this ugly disease 2 weeks ago. I had taken him in to vet starting in October with various ailments. I knew something was terribly wrong. He fainted on a Thursday night…diagnosed then and there and dead by Sunday…not without a blood transfusion, hospitalization and being ravaged by IMHA. I’m so mad…sad…and I miss my boy.

  17. Get your pets on BHT right away. It protects the lining of the red blood cell so they don’t die off prematurely. Our dog was diagnosed with IMHA 10 years ago and she is with us today because of BHT!

    1. Kim

      We saw your post and would appreciate any information you can provide about using BHT for IMHA. Our dog is on his third immunosuppressant and we are out of traditional options. What product do you use and what is the dose? Our dog is a Golden Retriever and weighs about 80 pounds.

      Thanks so much for your consideration!!!!!!!

  18. My chihuahua was almost 10. Fine one day the next day lethargic and not eating. Vet emergency visit showed IMHA. Meds and to a different vet. Blood transfusion done. Slightly better but blood work still off the charts. Passed away after 2 days. Still devastated. She didn’t deserve to die like this. I hope they find answers

  19. Please do not give up hope. We adopted a dog from a neighbor when he could no longer care for her. She is s Japanese Vhin and was 7 1/2 years old when we got her. We updated her vaccines and she checked out fine at our vet. Three weeks later she collapsed. We were in FL and after two visits to a vet in one day, she was rushed to UFL in Gainesville. She had a blood transfusion and was there 10 nights. Once she was released we had to take her back daily, then every other day, finally weekly. She is now 11 1/2 years old and has been in remission for the last 3 years. She is now fighting bladder cancer and we will be saying goodbye to her within days. But the IMHA was under control. She ended up taking Atopica for the IMHA. She has had reactions to flea medications and can only take Nexguard. She has had wonderful vet care and even survived two dental Durham’s one eye surgery. It is so hard to say goodbye but we will not let her suffer. Tonight is the first time she has whimpered. We jooecwe can make it through the weekend so our regular vet can help us say goodbye. But if we see she is hurting more, we will go to the ER vet.

  20. My 3 1/2 yr old little girl died from IMHA on Christmas day (2018). It was vaccine induced, 100% confirmed by the doctors. I am devastated, and frustrated at the BIG PHARM.
    This totally unacceptable.

    1. Hi there, my baby passed away two nights ago from imha. It seemed to occur overnight and I rushed her to the ER last week the meds did not help and she became jaundiced so I put her down. May I ask which vaccine did the doctors tell you caused your baby’s death? Because I have a feeling that may be the case for mine Thank You Kindly.

      1. I wis h I would have read this soon my 2 year old mini goldendoodle was put thro hell took her to the best hospital got one transfusion and went down hill more infections I didn’t no what to do I live her so much they put a tube down her thr oart nothing helped I looked in her sweet eyes told her I loved her so much. We put her to sleep the doctor said she was to sick. How do you have a great dog energy to dying in 6 days. I hope they find a cure I cry everyday and scared to get another dog that she will get it. Help

    2. I totally agree. I lost my baby boy to IMHA – again vaccine related and 100% confirmed. Broke my heart. It’s been 3.5 years and I miss him every day. That’s why I am overly cautious now. Unnecessary vaccinations are unacceptable in our house now.

  21. My standard poidle developed immune mediated meiningitis 24 hours after receiving a rabies vaccine. He has recovered completely but it took about 7 months, and at least 4 near-death episodes.

  22. Please Have Confidence,our ten yer old cocker maddie was struck down in november with imha,she had to have a blood transfusion and was treated with Prednisone only, now in March Maddies blood count is back to normal and she is back to her active self we do know it may return but we are remaining Positive.

    1. Thanks so much for this. Our precious dog was just diagnosed and has been hard reading through all of these bad outcomes. Nice to hear something hopeful.

  23. Our Boykin Spaniel was diagnosed in June of last year. She was four at the time. She was treated with antibiotics (in case there may have been a primary undetected infection going on) & prednisone.
    It was a long road, but as of December she was fully weaned off of the prednisone and has returned to her old self. The only visible effect at this time is the hair loss and weight gain she suffered as a result of being on the steroid that long.
    I will say though, we were fortunate to have caught it early, she did not need transfusions and her bone marrow never stopped producing red blood cells.
    I researched everything I could to be sure I was making informed decisions with my vet about her care and recovery. Fortunately for us, this treatment plan has worked – she responded well. It can always come back- which makes me very anxious and she can never have another vaccination…. but she is here and is herself.
    If your dog has been diagnosed, please collaborate with your vet; read vet studies (not just blog posts etc); and ask questions… do what feels right… there are no guarantees but positive outcomes do happen.
    For those of you that have lost pets to this disease, I am so sorry for your loss. Clearly, more needs to be done to determine triggers and causes as well as treatment. This article gives me hope for that…. as it may return to our baby girl at any time.

    1. Hi Melissa, Can you tell me why you decided to stick with prednisone only? My vet is recommending Atopica now. Lucy is currently on low dose prednisone, famotidine, sucralfate and b12 shots. Has been since December. I hate all the medications but know she needs them. Just afraid to now introduce Atopica. Lucy is a 9lb Pomeranian. 6 years old. My angel.

      1. Hi Whitney,
        My vet put our Bandit on the Prednisone, he said Bandit was one of the best dogs he has treated at having bone marrow that was great at making more red cells. He kept Bandit on antibiotic for a month since he’d had an anal glad infection less than a week prior to the IMHA diagnosis. Now we just do the steroid every 12 hours. No mention from my vet about Atopica. Bandit is a 12 year old Rat Terrier who was in great health until the infection. I’m so thankful it is down to just one pill. I keep hoping he will come back to his old self. I had to take him so many times and he was there for a week being treated, so now he wants nothing to do with me unless I’m giving him food 🙁

  24. I’ve got 2 dogs with these horrible diseases… one is a Great Dane with IMT. We don’t know what triggered it…. knock on wood but he is currently in remission and off all drugs. We have tried to get him off drugs in the passed and failed but are succeeding right now…. please hope it continues…

    My other dog is a pittie. I agreed to foster him after he was diagnosed with Vanessa and had signs of IMHA… we got him through the babesia but he now has Evan’s syndrome- IMHA and IMT… we have not been successful weaning him off of the drugs although he is down to a low dose of pred… he was only one when diagnosed and is now 3… I am thankful for every day with these two…

  25. My 4yr old English bulldog was diagnosed with this Saturday. She has had a blood transfusion and it has brought her count up. She is still very jaundice and she is still battling an upset stomach. This came out of nowhere, she has been in hospital for 3 days now. I’m a mess, shes a mess. Hardest thing to leave her there. Any advice on this disease? I’m scared and reading everything I can find. Our vet is wonderful, he specializes in Bulldogs and is over an hour away from our home. I would drive to the end of the world for my baby girl

    1. Darlene – my baby’s doctor worked and researched this in her efforts to help my baby. She’s no slouch. When things took a turn for the worst with my boy she was there. I told her I wanted to know that she learned something from all this because I needed to believe there would be some good in all of it. She said take the spleen, Always take the spleen. (She removed his after a lot of research) Please look into it. It’s been over 3.5 years but I remember it like yesterday. We couldn’t save him but I wouldn’t trade one day of the 11 months he survived with the condition for anything.

  26. Our 9 year old Yorkie Pom just suffered this IMHA disease. Never had any sickness and only went to the vet for normal check ups.I let her out in the backyard yesterday for a normal morning potty, she came back in, ran up the stairs into my room and started coughing. Her legs got weak and then she fell over. She didn’t seem to recover so we waited a few hours and took her to the vet to be diagnosed. They came back with the description of this disease and gave us 4 medicines for us to put her own. She panted all night and was still lethargic. She is normally a high energy dog but she just laid around. I took her outside this morning and her pee and poop was completely bloody. We took her back to the vet and they told us at this stage it was nothing more that they could do because she wasn’t recovering and her blood cells were extremely low. They told us she was suffering (and we could tell she was) so we had no choice but to put her to rest. This hurts tremendously because she was like my wife and I first daughter. I’ve never in my life seen a dog go from 100% fine with no symptoms to fatally ill in a matter of 24 hours. Devastating.

  27. My border collie was diagnosed with ImHA almost a week ago he’s been in the hospital he has had three blood transfusions it’s costing me over $12,000 and His numbers are only at 20 but he got up and he ate he look like a different dog now I want to take him home because I cannot afford to keep him in the hospital will he suffer if he comes home

  28. Took my golden ret. To get groomed came back started peeing blood took him to emergency vet there for three days seemed better .Took to reg vet every week reduced medicine blood count good went back blood count down increase meds He had relapse took back to emergency vet did blood transfusion did not help he would not eat had to put him down he was only 6 years old How can a dog be healthy one day & sick that afternoon he lasted only 2 months after being diagnosed

  29. My dog, 18 month old Labra-Doodle, lethargic, then peeing blood. This happened almost over night. Took her to vet, diagnosed with IMHA. PCV volume 17%. Got blood transfusion. Went to 28%. Fell to 20% or so. Blood transfusion. Went to 28%. Fell again. Plus she had very low platelet count. After she had 4 transfusions, vet suggested spleen removal. He said it often helps stabilize/fix/help etc. So, she got her spleen removed. Ended up needing another transfusion. She was in animal hospital for 16 days. Ended up getting her PCV to settle in around 36%. On the low side, but like the vet said, that may end up being her NEW normal. She was on Predisone (20mg 2x per day), as well as mycophenolate and clopidigrel. Long term prednisone use was taking its toll. She would get cuts that would be a battle to heal as her immune system was virtually non-existent because of pred and mycophenolate. She was bloated also. Panted constantly. She began to get a little closer to her old self, LOVING to play fetch. She’d play 24/7 if you let her. Started to try to wean her off. We had dropped the pred by 25%. Yesterday, August 9 at 9am, I had just given her morning meds, I turned around to put butter on my bagel, I heard a thud, she was on the ground dead. Instantly. I assume a blood clot got to her brain or heart, as that is a risk with IMHA dogs. Its a horrible disease and an expensive battle. 5 transfusions, splenectomy, drugs, 16 days in emergency animal hospital, weekly vet visits for blood tests, a total cost of OVER $21,000…. and we still lost her. It sounds like its a big crap shoot. Some dogs get by with 1 transfusion, some drugs and seem to pull through. We spared no expense in trying to save her, and still couldn’t. Best of luck to all of you.

  30. My beagle passed away with this terrible disease on Saturday after only 3 days. We still don’t know if it was primary or secondary. We are devastated. Hope a curs is found soon.

  31. My dog was diagnosed a year ago. She got stung by something in the dark when we let her out to go potty. She swelled up and then got better. Then she started peeing blood so the vet said she had a urinary track infection so she was put on meds and got better then relapsed 3 more times. So we found out that she had IMHA. She was kept for the weekend and was put on predispose for a while and then has been doing well.

  32. Such a terrible disease. I had to put my beautiful 11 year old Border Collie down today. It was a heartbreaker. The disease came on so fast. Saturday we were playing in the lake and then she wouldn’t eat, her stools were terribly loose and grayish yellow. I noted she was lethargic the next few days and her urine turned brown and I rushed her to the animal hospital. After blood and thorough examine, the results were that her anemia was dangerous and her white blood cells were attacking her red cells. Vet showed me her gums were white. She diagnosed IMHA from the physical exam and the blood test. She recommended euthanasia. Got a second opinion and the vet concurred that the humane thing to do since it had progressed so far was euthanasia. It really hurts to lose your best friend.

  33. We just lost our 12 yr old Bichon on Tuesday to IMHA. The Friday before he was vomiting some.Took him to a local vet and gave him someSub q fluids and antibiotics. Did the same thing on Sunday sub q fluids. We thought it was a GI infection and was hoping he would bounce back. On Sunday and Monday he was drinking water but still vomiting some. Only would eat soft food I put on a spoon but still has some
    Vomiting.Liver enzymes were slightly elevated at initial vet appt but 5 days later he was unresponsive. Took him to Emergency vet and bloodwork showed IMHA with very enlarged liver. Vet tried to stabilize him but his body just shit down. We are devastated about this. Keep asking myself if we missed something or could have stopped it? Emergency vet seemed to think there was some disease process happening for a while and finally showed up triggering the IMHA

  34. We just lost our 12 yr old Bichon on Tuesday to IMHA. The Friday before he was vomiting some.Took him to a local vet and gave him someSub q fluids and antibiotics. Did the same thing on Sunday sub q fluids. We thought it was a GI infection and was hoping he would bounce back. On Sunday and Monday he was drinking water but still vomiting some. Only would eat soft food I put on a spoon but still has some
    Vomiting.Liver enzymes were slightly elevated at initial vet appt but 5 days later he was unresponsive. Took him to Emergency vet and bloodwork showed IMHA with very enlarged liver. Vet tried to stabilize him but his body just shit down. We are devastated about this. Keep asking myself if we missed something or could have stopped it? Emergency vet seemed to think there was some disease process happening for a while and finally showed up triggering the IMHA.

      1. Sorry to hear about your Lab, hopefully he is still hanging in there.

        My 10yo poodle mix (normally 10.5-11 lbs) is now suffering badly from IMHA. She was Dx in Feb 2020 after initial illness from intestinal parasite.

        Hx: She was very healthy but picked up Bordetella at the groomer last October, she had been vaccinated. We did a steroid shot and antibiotics, she got better. Around Christmas, she ate some deer droppings (not unusual) and developed intestinal parasitic infection resulting in significant weight loss x 25% of her body weight. I opted for deworming Tx and more antibiotics along with probiotics and special food for GI health. (I chose not to have the $600 blood work at that time, thinking it was unnecessary) I deeply regret this.

        She began to improve and then declined late January: weakness, loss of appetite, and anorexia. Took her to another Vet, her hematocrite was low, Vet speculated a protein wasting disease, a GI bleed, a cancerous mass, or possibly a tick borne disease was causing IMHA and recommended an ultrasound to r/o cancerous mass. The ultrasound was negative for abdominal mass. Vet gave her IV fluids and vitamin B shot. We treated the anemia with prednisone, and doxycycline and restested CBC mid February, the level was at 17, again in 1 week and it dropped to 13. Did an emergency transfusion but only brought level up to 23 (>35 is normal)
        I continued the prednisone, doxycycline, Atopica, Sucralfate, and added Omeprazole for GI upset hoping to heal any GI bleed and stop anemia. My girl was doing great, she gained back the weight she lost (over 2 lbs !) and was running and jumping. She had a couple of days she didn’t feel great then a follow up visit in late April revealed hematocrite back down to 17. Dr said not much else to try except a chemotherapy drug Mycophenolate and if this doesn’t work its Hospice/palliative care, I am devastated. We changed to prednisolone liquid and added Metoclopramide for nausea. Vet gave her iron injection and sent her home. My girl pepped up after iron injection and initially had a good appetite. after 2 days on Mycophenolate, she lost appetite and has had off/on vomiting and diarrhea for the past week. The last three days she has not eaten voluntarily. I am syringe feeding 3-4 x /day, and dosing her seems to go on all day with 6 meds over 4 separate dosage times. She is very weak the past 3 days but wants to be near me every minute, I don’t think she is suffering at the moment though. This has been incredibly difficult, I wouldn’t wish it on anyone. I plan to keep on with the drugs this week and pray while I come to grips with this. I cannot afford another transfusion as I have spent thousands already. I can only hope for a cure for the future.

  35. First of all, you’re probably here because your best friend has been diagnosed IMHA and for that I want to say that I am so sorry.
    I don’t normally post to reddit or other places, I usually am one of the people searching for the information. So this is really my first post ever in attempt to help people with our story. When she was diagnosed with IMHA I spent hours searching for any information. When I tell you I was desperate there is really no way to describe how deeply I was in it. I can say with confidence this will be the first story you see like it. Perhaps that’s why I am so set on sharing this with the people seeking answers the way I was. I wish I had seen a post like this and I hope I am able to bring you any sense of peace even though this is going to be so hard to hear.
    Willow’s story:
    I got Willow Marie when she was just 6 weeks old along with her dear sister Lila May, two tiny papillon/long hair chihuahua mixes that looked like neither breed. They were my first dogs just on my own. I have taken better care of them than myself the last almost 7 years. They taught me so much about forgiveness because I fucked up with them sometimes. Twenty somethings are a trip. However I learned from them and with them, they gave me unconditional love something I had not experienced yet. We drove each other crazy sometimes but it was all in the name of love. I have loved these dogs with every fiber and molecule in my body. Willow took care of us all is the real truth to it. She cleaned her sister, and always made sure I was taking care of us all. She was vivacious, she made everyone laugh, and anyone that met her fell in love and she became part of them too. She was incredibly unique and she was truly everyone’s dog. We often called her Eeyore, because if she didn’t get exactly what she needed she would put on quite the sad act but I promise she always got what she wanted. Willow would get up every day when the sun came up whether I got up with her or not and demanded to start her day. She would greet the house with her gentle soul, and greet the birds… not so gently. So, when one random day she woke up at noon that was my first raised eye brow.
    As the week went on I noticed she seemed a little more down than usual but we were experiencing wildfires and the smoke was terrible so I was making her stay inside. Then my next concern was that she rode to one of her favorite places in the back seat curled up into herself. Then during the stay she just kind of stuck near us and didn’t really play. I kept it on my radar and told my partner that if she didn’t start acting better I would take her in because she seemed off. I tried taking her for a walk to see if that brightened her spirits and she was behind the pack. I watched her feeling it in my gut something was off. She would sit outside and still eat a bit so I wasn’t worried, but then she started to get worse. I thought I would give her one of her anxiety pills to see if that helped her at all and as I was giving it to her I noticed her gums were a little pale. My heart sank but I read that it could be from pain as well. I remembered a couple years before this girl had me in emergency and costing me $500.00 for a trapped fart and she had to be on pain meds. Makes sense right? Not really eating, tucking under herself, and pain. I went to our friends and she did really well with the new friends we were meeting. She wasn’t 100% herself but still had a good time. When we got home she chased a bunny 4 houses down and I thought jeez, she’s fine. I gave her little pats on her little slow buns with my foot all the way home and felt a lot of peace. She even ate when she went inside and all was well.
    Then I woke up a few hours later to her throwing up violently all the food she had eaten. She was weak and feeling so fragile. I put her in her spot and when I woke up she was looking even paler in the gums and just so tired. I rushed her to the emergency vet. I thought, I know my damn dog and I’m not waiting something is WRONG. I handed her off to the vet hoping she would make it to top priority because I couldn’t wait and neither could she. She made it to top priority and they began working on her and running a blood panel and a blood smear because. 1 hour later sitting in my car and shaking with anticipation for my best friend I got the call. I answered and she asked me about our recent activity, if she had gotten into anything, and there was no way. She was picky and didn’t eat anything that wasn’t delicious. After all of this she said “Willow is severely anemic and will need a blood transfusion as soon as possible, she has IMHA an autoimmune disease…” My whole entire world felt like it was paused.
    Now, I know that maybe you’ve heard and read stories like the ones above but this is where our story is unique to the other stories and threads. I don’t have 4,000 dollars, we couldn’t do the blood transfusion. I wanted to die right there on the phone with my partner, my dog was dying. I accused her of not being willing to try when she said we didn’t have the money, I immediately started beating myself to a pulp not having the money to save her. I told the vet that I was so sorry but I couldn’t do it and that I needed the next option. Those options were prednisone and azathioprine. We started the prednisone immediately, and then attempted to find azathioprine. It was hell, no one had it. We found a competent vet and went to her the following Monday for a second opinion who was confident at what we were looking at was IMHA. She told me that we weren’t at euthanasia yet, and to go get that second med and come back in a week. I was devastated for my sweet girl. She was miserable and I could see it but there was hope. I drove over two hours there and back to pick up the azathioprine because it had to be made for her. I was told its incredibly toxic and I had to handle with care. I thought, Jesus what is this going to do to my dog. All I cared about was getting her better. I went straight home and gave it to her.
    She hated her meds, and it was twice a day. The azathioprine was given at night and she would lick for hours after I gave it to her. She had constant diarrhea, she only ate bland meats and rice, and then spent the day hiding under our bed. I couldn’t get her to hang out with us, and days into it I noticed her tiny legs would shake holding herself up while giving kisses. I cried every day for her. I felt her muscle mass slipping away more and more every day and eventually when people would hold her or pick her up she would wheeze and she would struggle to breathe. Her breathing was fast and she even developed a heart murmur, I could quite literally see it beating in her chest. I spent hours of research. I even found that PROBIOTICS could send her into a relapse or create infection in a dog with IMHA, and I gave them daily probiotics. I got rid of everything that could hurt her. I carried her every where and tried my best to make her comfortable. I was ready to put her in a bubble and the vet said that if she ever reached remission she would have to be in one. Anything could trigger a relapse. She could never be vaccinated again, and never be around dogs that weren’t vaccinated or sick.
    So there we were. My sweet angel dog who would hike, kayak, run the fields for hours, take care of all of us, jump, howl, and run the whole dog park was withering away right in front of me. My desperation grew even though my loved ones tried to get through to me. I looked up meals good for anemia, I planned, I learned I did it all. I was giving her baby food with perfect ingredients, and gave her pedialyte and calorie replacements. I just wanted to get to our appointment and blood draw. Maybe just MAYBE they were wrong, and MAYBE this med would work, and and and. I lost sleep, my hips were bruised from laying on the floor watching her breathing. I looked for answers, looked for people and things to blamed. I remembered she took vaccines harder than her sister and swore them off (don’t do that). I was chained to an emotional roller coaster and then I just realized. Every time I saw her she was looking at me with desperate whale eyes. She was having anxiety. She was hiding all the time to protect herself because she was vulnerable. Willow Marie with the endless personality was slipping into a instinct only role. Her own sister would try and be near and willow would back off as if she was a threat. I had already lost my sweet girl.
    I couldn’t deal with it, and I kept going. I went to wal mart and I was obsessively checking labels and ingredients and it suddenly hit me. “What am I doing?” I asked myself for the first time. My dog is suffering. Her body is shutting down and its giving her anxiety. I was giving her anxiety. The pills, the food, the pedialyte. It was too much. I held her and I cried for the next few days. I talked to my friends and family and we cried together. I started seeking help in making the decision to end this awful ride for all of us. Willow has always hated pain, and she was in it. If I almost stepped on her she would scream.I was asking her to fight something that was her worst nightmare. Weekly blood draws, toxic medication, and just the physical pain already occurring. I couldn’t ask her to do this. I felt guilt just thinking about it. Nothing major had happened yet. No collapsing, nothing was turning yellow. She wasn’t “there” but you guys… she was. She told me she was with her eyes full of anxiety and not even I could comfort her. When your dog doesn’t even want your comfort anymore, something isn’t right.
    Since I had them and since I knew it was an option I always said I would do it at home if I had the opportunity. I started half heartedly searching for one and found Lindsey Mccalister from Heart in Home Vet in Vancouver, WA. I emailed her and I told her our story, she immediately said she was sorry. We talked quite a bit and we even spoke on the phone. I told her I didn’t know what to do and that I was so scared of doing the wrong thing. However, I couldn’t bare my girl or myself going though a blood clot, a organ completely failing, seizures, collapsing, the risk list goes on. She told me that the only way to ensure a peaceful passing and not have a crisis is giving her the chance to go in peace sooner than later while she still has dignity and it isn’t in a cold room on a metal table (please if you do it this way, its your choice, this is just my interpretation and what I believe my dog wanted, willow HATED the vet.) Lindsey knew my heart was broken and never pressured me into anything, but did agree that this was the kindest thing I could do.
    So I decided I loved my best friend too much to let her continue to suffer. I am crying right now just typing this. It was absolutely the hardest thing I have ever had to do, but like many of you I would do anything for my dogs. I canceled the blood draw for that Monday and had Lindsey come instead. I couldn’t imagine this life for a pup who loved life, the outdoors, and hated needles and vets. Living in a bubble and enduring the next year of toxic meds, and maybe forever was just not it. The day before we sat in the sun, she marked her siblings pee and let them know she’s still a baddie and runs the coop. We had snacks and for dinner that little thing ate 1/2lb cheese burger which left her a little gassy which doesn’t normally. Her body was telling all of us that is was working so hard. It was a long last night, she was up and down. And she next day she was so shaky, but still giving me kisses. I let her do what she wanted and helped her around until Lindsey came. We went over the paperwork and process. I let Willow get some water and go potty, and then I picked up my baby and took her outside and put her on the bed we laid out in the sun and the shade. I hugged and kissed her and Lindsey gave her the sedative. She screamed, I won’t lie and it killed me. But I then got down with her and within 15 seconds she was surrounded by her favorite people and was getting all the snacks. For a moment her sweet eyes looked at me and I saw my happy little girl again before she drifted off to sleep in my hands. Once she was out Lindsey came to administer the second shot. She was so gentle to all of us. Willow let go easily and quietly, and I believe that was a sign in itself.
    It’s been just a couple days and I have cried my way through most of them. I have gone through guilt, denial, panic that I did the wrong thing, acceptance, and then back through it all again. I was really hurting last night, we made the bed and I didn’t have to prep her spot because she slept on my head every night. I got in bed and started looking though pictures and videos. I was quickly reminded who my girl was. A tiny but mighty loud little gremlin that never slowed down for anyone or anything. Until IMHA showed up in our lives.
    I am writing this partly for the release and in honor of my sweet Willow Marie, but mostly because I have a different story than everyone I read about. I didn’t spend 4k-20k on blood transfusions only to lose her anyway. She never spent a week in the hospital missing me. She never had to have strangers poke her and hurt her even if it supposed to help. She didn’t have to go through anymore pain and suffering than she was in. It was genuinely the hardest thing I have ever done, but I was able to do it because I loved her. I never truly understood loving someone so much you’re willing to let go until now. IMHA is not something deeply understood. Unless there is another issue causing it, you aren’t even going to be able to know what it was. I asked myself so many questions, was it the vaccines, the tick when she was 2, was it environment, the flea treatment, was it me, did she eat something, was it the probiotics. I will never know. However, I do know that I did the right thing for Willow. And I am struggling every minute, but she isn’t going through this anymore. She’s free, like she was before IMHA.
    I’m not telling you what to do here, I just wish I had something like this to read when I was feeling desperate and unsure. The truth is, you know your best friend. You know what they want and don’t want. If you aren’t sure, they will tell you. If you think they aren’t, you’re just not listening. So put down the phone and close the computer. Be with them, they are terrified, and they’re body is trying to kill them. They need you to be present and they need your help whatever that looks like for them, not you. You need to ask them and yourself what the next step is. If it feels like it’s impossible, then it’s probably the right answer. Trying to save her was easy for me and harder on her and I would have done it for the rest of her life. But I loved her too much. She never let me suffer a day in my life, why would I let her suffer.
    Again, I want to say that I’m sorry. I also want you to know it’s not your fault no matter how you got here. I know you’re losing your best friend but this doesn’t mean anything for the time you have spent together. You still have all of those times. If they are hiding from you, it’t not you, they still love you and you are still they’re best friend and that’s why they are hiding. To protect you, and themselves. I know it’s hard to make the decision, and I know it’s hard to realize that sometimes our help hurt’s. But, we have to hear it.
    Love them, hold them, never forget them, and please god if you can help it do not leave their side as they move on. I was there for every minute of it and I would regret otherwise.
    Willow, it was truly in honor in life and death my dearest friend.