what is the current treatment protocol for IMHA in dogs including immunosuppression, anticoagulation, and monitoring?

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Glucocorticoids are the cornerstone of immunosuppression for canine immune-mediated hemolytic anemia (IMHA), and anticoagulant therapy should be initiated at the time of diagnosis. Case fatality rates approach 50%, with thromboembolic disease among the most common causes of death, and thromboembolism has been estimated to occur in up to 50–80% of affected dogs.2 --- Immunosuppression: First-Line Prednisone or prednisolone is first-line immunosuppression, with dexamethasone used parenterally in dogs that cannot tolerate oral administration.3 A reported induction protocol uses dexamethasone at 0.5 mg/kg IV q24h, transitioning to prednisone at 2 mg/kg PO q12h once oral administration is feasible.3 Methylprednisolone is an acceptable alternative with similar anti-inflammatory potency to prednisolone and prednisone, and is available as an injectable formulation useful in the acute phase.4 Many dogs can be managed satisfactorily with glucocorticoids alone; others develop life-threatening disease or severe steroid-induced adverse effects requiring additional immunosuppression.4 --- Immunosuppression: Second-Line Second-line agents — mycophenolate mofetil (MMF), cyclosporine, azathioprine, and leflunomide — are added when glucocorticoid monotherapy is insufficient or adverse effects are unacceptable.16 The addition of a second immunosuppressive agent allows more rapid glucocorticoid tapering, which is particularly relevant in larger-breed dogs where corticosteroid intolerance is more prevalent.5 A clear survival benefit of adding second-line drugs to a standard steroid protocol has not been established.4 Cyclosporine is a commonly used second-line agent; one protocol uses 2.5 mg/kg PO q12h, which is considered therapeutic based on prior IMHA studies, though the ACVIM consensus statement recommends a higher dose.4 Cyclosporine administration is associated with a significant increase in thromboxane A2 synthesis in dogs, particularly at peak blood concentrations with immunosup