treatment protocol to follow with drugs and dosage in detail for imtp in dogs

Reading File

Finding Sources

Searching PubMed

immune-mediated thrombocytopenia dogs treatment

Finding Sources

Searching the Web

IMTP immune-mediated thrombocytopenia dogs treatment protocol drugs dosage 2024

Reading Web Page

https://pmc.ncbi.nlm.nih.gov/articles/PMC11256181

Reading Web Page

https://www.dvm360.com/view/overcoming-diagnostic-and-therap…

Here is a detailed IMTP (Immune-Mediated Thrombocytopenia) treatment protocol for dogs, based on the 2024 ACVIM Consensus Statement and current clinical evidence.

IMTP in Dogs - Detailed Treatment Protocol

Overview of Goals

Primary goal: Achieve platelet count ≥100,000/µL without bleeding
Minimize complications from immunosuppressive therapy
Treatment must be individualized based on disease severity

Response Definitions (2024 ACVIM)

Category	Definition
No response	Platelet count <30,000/µL or ongoing bleeding after 2 weeks
Partial response	Platelet count 30,000-100,000/µL with >2-fold increase from baseline, no bleeding
Complete response	Platelet count ≥100,000/µL, no bleeding
Full remission	Platelet count ≥100,000/µL, no bleeding, off all treatment

STEP 1 - Initial Stabilization (Emergency Support)

Before immunosuppression is started:

IV fluids: Crystalloids (e.g., lactated Ringer's or 0.9% NaCl) for hypovolemia. Avoid synthetic colloids (hemodilution can reduce platelet function); use plasma as an alternative if colloid support is needed.
Packed RBCs or whole blood: If severe anemia from hemorrhage is present
GI protectants: Consider omeprazole (0.7-1 mg/kg PO/IV q24h) or famotidine (0.5-1 mg/kg PO/IV q12-24h) if GI hemorrhage is suspected (evidence is limited but commonly used)
Barium sulfate (oral): Some clinicians administer a diagnostic dose to help coat and protect GI mucosa in active GI bleeding - an empirical technique
Discontinue any drugs that impair platelet function (NSAIDs, aspirin)
Doxycycline: 5-10 mg/kg PO or IV q12h pending tick-borne disease serology (empirical treatment for Ehrlichia/Anaplasma until ruled out)
Topical ophthalmic steroids (1% prednisolone acetate or 0.1% dexamethasone phosphate 3-4x/day) if hyphema is present

STEP 2 - First-Line Immunosuppression

2a. Glucocorticoids (MANDATORY - cornerstone of treatment)

Drug	Dose	Route	Frequency
Prednisolone (preferred over prednisone)	2-4 mg/kg/day	PO	Once daily or divided q12h
Prednisone	2-4 mg/kg/day	PO	Once daily or divided q12h
Dexamethasone (if cannot take oral)	0.2-0.3 mg/kg	IV	q24h

Platelet numbers typically begin rising within 5-7 days
Most dogs reach platelet counts of 50,000-100,000/µL within 7 days
Continue induction dose for at least 2-3 weeks or until platelet count is stable ≥100,000/µL

2b. Vincristine (Adjunctive - for severe/bleeding cases)

Drug	Dose	Route	Frequency
Vincristine	0.02 mg/kg IV (max 0.5 mg/m² for dogs >25 kg)	IV	Single dose only

When to use: Dogs with clinically relevant bleeding and/or platelet count <10,000-20,000/µL

Mechanism: Stimulates megakaryocytes to release platelets prematurely; median time to platelet count ≥40,000/µL is approximately 3-4 days post-administration

Important caveats:

Use caution in breeds with ABCB1/MDR1 mutation (Collies, Australian Shepherds, Shetland Sheepdogs) - increased vincristine toxicity risk
Delay starting cyclosporine by several days after vincristine (cyclosporine inhibits vincristine metabolism, increasing neutropenia risk)
Requires chemotherapy handling precautions for staff and owners

2c. Human IV Immunoglobulin (hIVIg) - Alternative/Adjunct to Vincristine

Drug	Dose	Route	Duration
hIVIg	0.5-1.5 g/kg	IV infusion	Over 6-12 hours (single infusion)

Has comparable effect to vincristine in accelerating platelet recovery
Reserved for dogs with severe bleeding or no response to glucocorticoids
Very expensive - limits routine use
Not recommended as sole agent - always combine with glucocorticoids

STEP 3 - Second-Line Immunosuppression

Add a second immunosuppressant if:

No response within 5-7 days of starting glucocorticoids
Relapse during glucocorticoid tapering
Severe glucocorticoid side effects develop
Dog >25 kg (to allow faster steroid tapering)
Severe bleeding requiring more aggressive control

Choose ONE of the following (based on clinician preference and patient factors):

Option A - Azathioprine (most commonly used)

Drug	Dose	Route	Schedule
Azathioprine	2 mg/kg/day	PO	q24h for first 2-4 weeks, then taper to every other day (q48h)

Onset of action: 2-4 weeks (delayed - so start early if second-line is anticipated)
Side effects: Myelosuppression, hepatotoxicity, pancreatitis
Monitor CBC (especially neutrophil count) every 1-2 weeks initially, then monthly
Do NOT use in cats (causes fatal bone marrow suppression)

Option B - Modified Cyclosporine

Drug	Dose	Route	Schedule
Cyclosporine (modified, e.g., Atopica)	5 mg/kg	PO	q12-24h

Check blood levels if using q24h (target trough: 200-400 ng/mL for immune-mediated disease)
Side effects: Vomiting, diarrhea, anorexia, gingival hyperplasia, opportunistic infections
Delay by several days after vincristine to reduce neutropenia risk

Option C - Mycophenolate Mofetil (MMF)

Drug	Dose	Route	Schedule
Mycophenolate mofetil	10-15 mg/kg	PO	q12h

Alternative in dogs intolerant of azathioprine
Side effects: GI upset (diarrhea most common), bone marrow suppression

Option D - Leflunomide

Drug	Dose	Route	Schedule
Leflunomide	2-4 mg/kg/day	PO	Once daily

Used when other options are not tolerated or have failed
Side effects: Hepatotoxicity, bone marrow suppression

STEP 4 - Refractory / Salvage Options

For dogs failing Steps 2 and 3:

Option	Notes
Splenectomy	Reserved for truly refractory cases; removes the primary site of platelet destruction and antiplatelet antibody production
Danazol (synthetic androgen)	5-10 mg/kg PO q12h; reduces platelet destruction; slow onset (weeks to months)
Cyclophosphamide	50 mg/m² PO on days 1-4 of each week; maximum 4-5 months; reserved for refractory cases - less favored due to toxicity
Thrombopoietin receptor agonists (e.g., eltrombopag, romiplostim)	Emerging use in refractory IMTP; stimulate platelet production
Therapeutic plasma exchange (plasmapheresis)	Not routinely recommended per 2024 ACVIM guidelines

STEP 5 - Monitoring Protocol

Timeframe	Action
Initial (platelet count <40,000-50,000/µL)	Hospitalize; CBC every 2-3 days
Outpatient (platelet count >40,000-50,000/µL)	Recheck every 1-2 weeks during active treatment
During taper	Confirm platelet count immediately before each dose reduction
Liver/kidney function	Monitor throughout treatment (baseline, then every 4-8 weeks)
Azathioprine monitoring	CBC + liver enzymes q1-2 weeks for first month, then q2-4 weeks

STEP 6 - Tapering Protocol

Once complete response is achieved and sustained for a few weeks:

Reduce glucocorticoid dose by 20-25% every 2-4 weeks, confirming platelet count is stable before each reduction
Taper azathioprine/second-line drug in tandem once glucocorticoids are near discontinuation
Total treatment duration: typically 3-6 months minimum; some dogs require lifelong therapy at the lowest effective dose

Relapse during tapering:

Mild relapse: Return to the most recent effective dose
Severe relapse: Restart full induction protocol; consider vincristine/hIVIg again (hIVIg only if not previously used)
All future tapers should be more gradual (double intervals or decrease decrements)
Lifelong treatment at lowest achievable dose may be necessary for recurrent relapses

Summary Drug Table

Drug	Dose	Route	Notes
Prednisolone	2-4 mg/kg/day	PO	First-line; continue 2-3+ weeks
Dexamethasone	0.2-0.3 mg/kg	IV	If oral not possible
Vincristine	0.02 mg/kg (max 0.5 mg/m²)	IV	Single dose; for active bleeding
hIVIg	0.5-1.5 g/kg	IV over 6-12h	Expensive; alternative to vincristine
Azathioprine	2 mg/kg/day → q48h	PO	Second-line; onset 2-4 weeks
Cyclosporine (modified)	5 mg/kg q12-24h	PO	Second-line; delay after vincristine
MMF	10-15 mg/kg q12h	PO	Second-line alternative
Leflunomide	2-4 mg/kg/day	PO	Second-line alternative
Doxycycline	5-10 mg/kg q12h	PO/IV	Empirical for tick-borne disease
Cyclophosphamide	50 mg/m² days 1-4/week	PO	Refractory only; max 4-5 months
Danazol	5-10 mg/kg q12h	PO	Refractory adjunct; slow onset

Key Points for Practice

Prednisolone is preferred over prednisone in dogs because prednisone requires hepatic conversion to prednisolone, which may be less reliable
ABCB1/MDR1 breeds (Collies, Australian Shepherds, Shelties, etc.) - use extra caution with vincristine; consider genetic testing
Vaccination during or after IMTP: Only after immunosuppression is reduced to anti-inflammatory doses or stopped; administer one vaccine at a time; monitor platelet count at 2 and 5 weeks post-vaccination
Do NOT use antithrombotics (aspirin, clopidogrel) unless there is a concurrent prothrombotic condition
Gastroprotectants are not routinely recommended unless GI bleeding is suspected

Sources: 2024 ACVIM Consensus Statement on Treatment of ITP in Dogs and Cats (LeVine et al., JVIM 38(4):1982-2007); PASE Veterinary - IMTP in Dogs; DVM360 - IMTP therapeutic challenges

Create a treatment decision flowchart for IMTP in dogs (PDF)

Reading File

Running Command

mkdir -p /tmp/workspace/imtp-flowchart && ls /tmp/workspace/imtp-flowchart/

Writing File

~/imtp-flowchart/create_flowchart.py

from reportlab.lib.pagesizes import A3, landscape
from reportlab.pdfgen import canvas
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.lib.colors import HexColor
import math

# ── colour palette ──────────────────────────────────────────────────────────
C_TITLE_BG   = HexColor("#1A3A5C")   # deep navy
C_TITLE_FG   = colors.white
C_START      = HexColor("#1A3A5C")   # oval start
C_EMERGENCY  = HexColor("#C0392B")   # red
C_FIRST      = HexColor("#1A6B3C")   # dark green
C_SECOND     = HexColor("#1565C0")   # deep blue
C_MONITOR    = HexColor("#6A0DAD")   # purple
C_TAPER      = HexColor("#E67E22")   # orange
C_REFRACTORY = HexColor("#7F8C8D")   # grey
C_DIAMOND    = HexColor("#F5A623")   # decision yellow
C_REMISSION  = HexColor("#27AE60")   # bright green
C_LIGHT_GREY = HexColor("#F4F6F9")
C_BOX_STROKE = HexColor("#2C3E50")
WHITE        = colors.white

OUTPUT = "/tmp/workspace/imtp-flowchart/IMTP_Treatment_Flowchart.pdf"
PAGE_W, PAGE_H = landscape(A3)

c = canvas.Canvas(OUTPUT, pagesize=landscape(A3))
c.setTitle("IMTP in Dogs – Treatment Decision Flowchart")

# ═══════════════════════════════════════════════════════════════════════════
# Helper functions
# ═══════════════════════════════════════════════════════════════════════════

def rounded_rect(canvas_obj, x, y, w, h, r, fill_color, stroke_color=C_BOX_STROKE,
                 stroke_width=1.2):
    """Draw a filled rounded rectangle."""
    canvas_obj.setFillColor(fill_color)
    canvas_obj.setStrokeColor(stroke_color)
    canvas_obj.setLineWidth(stroke_width)
    canvas_obj.roundRect(x, y, w, h, r, fill=1, stroke=1)


def draw_box(canvas_obj, cx, cy, w, h, title, lines, fill_color,
             title_color=WHITE, text_color=WHITE,
             font_title="Helvetica-Bold", font_body="Helvetica",
             title_size=8, body_size=7, r=5):
    """Draw a labelled process box centred at (cx, cy)."""
    x = cx - w / 2
    y = cy - h / 2
    rounded_rect(canvas_obj, x, y, w, h, r, fill_color)
    # title bar
    bar_h = title_size + 5
    canvas_obj.setFillColor(HexColor("#00000033"))
    canvas_obj.roundRect(x, y + h - bar_h, w, bar_h, r, fill=1, stroke=0)
    canvas_obj.setFillColor(title_color)
    canvas_obj.setFont(font_title, title_size)
    canvas_obj.drawCentredString(cx, y + h - bar_h + 3, title)
    # body lines
    canvas_obj.setFillColor(text_color)
    canvas_obj.setFont(font_body, body_size)
    start_y = y + h - bar_h - body_size - 3
    for line in lines:
        canvas_obj.drawCentredString(cx, start_y, line)
        start_y -= body_size + 2


def draw_diamond(canvas_obj, cx, cy, w, h, label, sublabel="",
                 fill_color=C_DIAMOND, text_color=WHITE):
    """Draw a decision diamond centred at (cx, cy)."""
    canvas_obj.setFillColor(fill_color)
    canvas_obj.setStrokeColor(C_BOX_STROKE)
    canvas_obj.setLineWidth(1.2)
    path = canvas_obj.beginPath()
    path.moveTo(cx,       cy + h/2)
    path.lineTo(cx + w/2, cy)
    path.lineTo(cx,       cy - h/2)
    path.lineTo(cx - w/2, cy)
    path.close()
    canvas_obj.drawPath(path, fill=1, stroke=1)
    canvas_obj.setFillColor(text_color)
    canvas_obj.setFont("Helvetica-Bold", 8)
    canvas_obj.drawCentredString(cx, cy + 3, label)
    if sublabel:
        canvas_obj.setFont("Helvetica", 7)
        canvas_obj.drawCentredString(cx, cy - 9, sublabel)


def arrow(canvas_obj, x1, y1, x2, y2, label="", label_side="right",
          color=C_BOX_STROKE, lw=1.2):
    """Draw an arrow from (x1,y1) to (x2,y2) with optional label."""
    canvas_obj.setStrokeColor(color)
    canvas_obj.setLineWidth(lw)
    canvas_obj.line(x1, y1, x2, y2)
    # arrowhead
    angle = math.atan2(y2 - y1, x2 - x1)
    ah = 7
    aw = 4
    ax1 = x2 - ah * math.cos(angle) + aw * math.sin(angle)
    ay1 = y2 - ah * math.sin(angle) - aw * math.cos(angle)
    ax2 = x2 - ah * math.cos(angle) - aw * math.sin(angle)
    ay2 = y2 - ah * math.sin(angle) + aw * math.cos(angle)
    canvas_obj.setFillColor(color)
    p = canvas_obj.beginPath()
    p.moveTo(x2, y2)
    p.lineTo(ax1, ay1)
    p.lineTo(ax2, ay2)
    p.close()
    canvas_obj.drawPath(p, fill=1, stroke=0)
    if label:
        canvas_obj.setFillColor(C_BOX_STROKE)
        canvas_obj.setFont("Helvetica-Bold", 7)
        mx, my = (x1+x2)/2, (y1+y2)/2
        if label_side == "right":
            canvas_obj.drawString(mx + 3, my, label)
        else:
            canvas_obj.drawRightString(mx - 3, my, label)


def oval(canvas_obj, cx, cy, w, h, text, fill_color=C_START, text_color=WHITE):
    canvas_obj.setFillColor(fill_color)
    canvas_obj.setStrokeColor(C_BOX_STROKE)
    canvas_obj.setLineWidth(1.5)
    canvas_obj.ellipse(cx - w/2, cy - h/2, cx + w/2, cy + h/2, fill=1, stroke=1)
    canvas_obj.setFillColor(text_color)
    canvas_obj.setFont("Helvetica-Bold", 9)
    canvas_obj.drawCentredString(cx, cy - 3, text)


# ═══════════════════════════════════════════════════════════════════════════
# PAGE BACKGROUND
# ═══════════════════════════════════════════════════════════════════════════
c.setFillColor(C_LIGHT_GREY)
c.rect(0, 0, PAGE_W, PAGE_H, fill=1, stroke=0)

# ── Title bar ───────────────────────────────────────────────────────────────
c.setFillColor(C_TITLE_BG)
c.rect(0, PAGE_H - 48, PAGE_W, 48, fill=1, stroke=0)
c.setFillColor(WHITE)
c.setFont("Helvetica-Bold", 18)
c.drawCentredString(PAGE_W/2, PAGE_H - 28, "IMTP in Dogs – Treatment Decision Flowchart")
c.setFont("Helvetica", 9)
c.drawCentredString(PAGE_W/2, PAGE_H - 42,
    "Immune-Mediated Thrombocytopenia  |  Based on 2024 ACVIM Consensus Statement")

# ── Footer ───────────────────────────────────────────────────────────────────
c.setFillColor(C_TITLE_BG)
c.rect(0, 0, PAGE_W, 18, fill=1, stroke=0)
c.setFillColor(WHITE)
c.setFont("Helvetica", 7)
c.drawCentredString(PAGE_W/2, 5,
    "Reference: LeVine DN, Goggs R, Kohn B et al. ACVIM Consensus Statement on Treatment of ITP. J Vet Intern Med 2024;38(4):1982-2007")

# ═══════════════════════════════════════════════════════════════════════════
# LEGEND
# ═══════════════════════════════════════════════════════════════════════════
legend_items = [
    (C_START,      "Start / End"),
    (C_EMERGENCY,  "Emergency Support"),
    (C_FIRST,      "First-Line Tx"),
    (C_SECOND,     "Second-Line Tx"),
    (C_MONITOR,    "Monitoring"),
    (C_TAPER,      "Taper Protocol"),
    (C_REFRACTORY, "Refractory Tx"),
    (C_DIAMOND,    "Decision Point"),
    (C_REMISSION,  "Remission"),
]
lx = PAGE_W - 170
ly = PAGE_H - 70
c.setFillColor(WHITE)
c.setStrokeColor(C_BOX_STROKE)
c.setLineWidth(0.8)
c.roundRect(lx - 8, ly - len(legend_items)*14 - 4, 170, len(legend_items)*14 + 20, 4, fill=1, stroke=1)
c.setFillColor(C_TITLE_BG)
c.setFont("Helvetica-Bold", 8)
c.drawString(lx, ly + 4, "LEGEND")
for i, (col, lbl) in enumerate(legend_items):
    yy = ly - 12 - i*14
    c.setFillColor(col)
    c.setStrokeColor(C_BOX_STROKE)
    c.setLineWidth(0.5)
    c.roundRect(lx, yy, 12, 10, 2, fill=1, stroke=1)
    c.setFillColor(C_BOX_STROKE)
    c.setFont("Helvetica", 7.5)
    c.drawString(lx + 16, yy + 1.5, lbl)

# ═══════════════════════════════════════════════════════════════════════════
# LAYOUT  (all coords in points; A3 landscape = 1191 x 842 pt)
# Main column X positions
# ═══════════════════════════════════════════════════════════════════════════
# We lay the flowchart top-to-bottom with some branching left/right.

# ── X coordinates of main lane ───────────────────────────────────────────
MX = 340          # main centre-x
BW = 210          # box width  (main)
BH = 60           # box height (main)
BW2 = 175         # second-line box width
BH2 = 75

# ── Y positions (from top of usable area, below title bar) ────────────────
TOP  = PAGE_H - 60   # just under title
USABLE = TOP - 22    # above footer

# Row centres (y)
R = {}
R[0]  = USABLE - 35        # START oval
R[1]  = R[0]  - 65         # Emergency stabilisation
R[2]  = R[1]  - 75         # D1: Bleeding / platelet < 20k?
R[3]  = R[2]  - 75         # Vincristine / hIVIg box (left branch)
R[4]  = R[3]  - 10         # merge back
R[5]  = R[2]  - 65         # Glucocorticoids (first line)  ← same level merge
R[6]  = R[5]  - 75         # D2: Response at day 5-7?
R[7]  = R[6]  - 70         # Add second-line immunosuppressant
R[8]  = R[7]  - 80         # Second-line options (multi-box)
R[9]  = R[8]  - 80         # D3: Response at 2 weeks?
R[10] = R[9]  - 70         # Refractory options
R[11] = R[6]  - 0          # (right branch of D2 – complete response)
R[12] = R[9]  - 0          # (right branch of D3 – complete response merge)
R_MONITOR = R[7] - 15      # monitoring block on right
R_TAPER   = R[9]  - 140    # taper block (right of D3 yes)
R_REMIS   = R_TAPER - 75   # full remission

# ── Recalculate cleaner layout ────────────────────────────────────────────
# Use explicit y values to avoid overlap
y_start   = USABLE - 30
y_emerg   = y_start  - 68
y_d1      = y_emerg  - 80     # diamond: clinically significant bleeding?
y_adjunct = y_d1     - 80     # vincristine / hIVIg (left branch)
y_firstl  = y_adjunct - 55    # merge → first-line glucocorticoids
y_d2      = y_firstl - 82     # diamond: response day 5-7?
y_second  = y_d2     - 82     # add second-line drug
y_opts    = y_second - 85     # four option boxes
y_d3      = y_opts   - 82     # diamond: complete response at 2 weeks?
y_refrac  = y_d3     - 82     # refractory measures
y_end     = y_refrac - 65     # refractory end

# Right-side taper track
y_taper   = y_d2     - 55     # taper protocol (right of D2 YES)
y_d_rem   = y_taper  - 80     # diamond: full remission?
y_remis   = y_d_rem  - 70     # full remission oval
y_relapse = y_d_rem  - 0      # relapse path goes right

# Monitor box (far right)
MONX = MX + 290
MON_W = 165
MON_H = 100

# ─────────────────────────────────────────────────────────────────────────
# ROW 0 – START
# ─────────────────────────────────────────────────────────────────────────
oval(c, MX, y_start, 200, 32, "Dog with Suspected IMTP",
     fill_color=C_START)

arrow(c, MX, y_start - 16, MX, y_emerg + BH/2)

# ─────────────────────────────────────────────────────────────────────────
# ROW 1 – Emergency Stabilisation
# ─────────────────────────────────────────────────────────────────────────
draw_box(c, MX, y_emerg, BW+30, BH+15, "EMERGENCY STABILISATION",
    ["IV fluids (crystalloids / plasma if colloid needed)",
     "Blood products (pRBC / whole blood) if severe anaemia",
     "Doxycycline 5-10 mg/kg PO/IV q12h (pending tick titres)",
     "Discontinue NSAIDs / platelet-inhibiting drugs",
     "GI protectants if GI haemorrhage suspected"],
    C_EMERGENCY, title_size=8, body_size=6.5, r=6)

arrow(c, MX, y_emerg - BH/2 - 7, MX, y_d1 + 32)

# ─────────────────────────────────────────────────────────────────────────
# ROW 2 – DIAMOND 1: Clinically significant bleeding or plt < 20,000?
# ─────────────────────────────────────────────────────────────────────────
draw_diamond(c, MX, y_d1, 260, 60,
             "Clinically significant bleeding",
             "or platelet count < 20,000/µL?")

# YES branch (left)
LBX = MX - 190   # left branch X
arrow(c, MX - 130, y_d1, LBX + 85, y_d1, label="YES", label_side="left")
arrow(c, LBX, y_d1, LBX, y_adjunct + BH/2)

draw_box(c, LBX, y_adjunct, 165, BH + 5,
    "ADJUNCTIVE (choose one)",
    ["Vincristine 0.02 mg/kg IV (single dose)",
     "  max 0.5 mg/m² if > 25 kg",
     "OR hIVIg 0.5–1.5 g/kg IV over 6-12 h",
     "  (if not used previously / high cost)"],
    C_FIRST, title_size=7.5, body_size=6.5, r=5)

# re-join arrow from adjunct box down to firstl
arrow(c, LBX, y_adjunct - BH/2 - 5, LBX, y_firstl + BH/2,
      color=HexColor("#555555"))
arrow(c, LBX, y_firstl, MX - BW/2 - 5, y_firstl,
      color=HexColor("#555555"))

# NO branch (straight down)
arrow(c, MX, y_d1 - 30, MX, y_firstl + BH/2, label="NO")

# ─────────────────────────────────────────────────────────────────────────
# ROW 3 – First-line: Glucocorticoids
# ─────────────────────────────────────────────────────────────────────────
draw_box(c, MX, y_firstl, BW + 20, BH + 20,
    "FIRST-LINE: GLUCOCORTICOIDS",
    ["Prednisolone 2–4 mg/kg/day PO  (preferred)",
     "OR Prednisone 2–4 mg/kg/day PO",
     "OR Dexamethasone 0.2–0.3 mg/kg IV q24h",
     "    (if oral administration not possible)",
     "Continue induction dose ≥ 2–3 weeks"],
    C_FIRST, title_size=8, body_size=6.8, r=6)

arrow(c, MX, y_firstl - BH/2 - 10, MX, y_d2 + 32)

# ─────────────────────────────────────────────────────────────────────────
# MONITORING BOX (right side, beside first-line)
# ─────────────────────────────────────────────────────────────────────────
mon_cx = MX + 290
mon_cy = y_firstl - 30
draw_box(c, mon_cx, mon_cy, MON_W, MON_H + 10,
    "MONITORING",
    ["CBC every 2-3 days if plt < 40,000/µL",
     "Hospitalise if plt < 40-50 × 10⁹/L",
     "Outpatient if plt > 40-50 × 10⁹/L",
     "Recheck plt every 1-2 wks during taper",
     "LFTs + renal panel baseline, then q4-8 wks",
     "If azathioprine: CBC + LFTs q1-2 wks × 1 mo"],
    C_MONITOR, title_size=8, body_size=6.5, r=5)
# dashed connector
c.setDash(4, 3)
c.setStrokeColor(C_MONITOR)
c.setLineWidth(1)
c.line(MX + BW/2 + 10, y_firstl, mon_cx - MON_W/2, mon_cy + 5)
c.setDash()   # reset

# ─────────────────────────────────────────────────────────────────────────
# ROW 4 – DIAMOND 2: Response at day 5-7?
# ─────────────────────────────────────────────────────────────────────────
draw_diamond(c, MX, y_d2, 250, 60,
             "Response at Day 5–7?",
             "(plt rising / no active bleeding)")

# YES → right to taper track
TAPX = MX + 290   # right track X
arrow(c, MX + 125, y_d2, TAPX - 82, y_d2, label="YES")

draw_box(c, TAPX, y_d2, 160, BH + 15,
    "TAPER GLUCOCORTICOIDS",
    ["Reduce dose ~20-25% every 2-4 wks",
     "Confirm plt stable BEFORE each reduction",
     "Also taper 2nd-line drug in tandem",
     "Total duration: typically 3-6 months",
     "More gradual if prior relapse history"],
    C_TAPER, title_size=7.5, body_size=6.5, r=5)

# diamond below taper: full remission?
y_d_rem2 = y_d2 - 100
draw_diamond(c, TAPX, y_d_rem2, 175, 52,
             "Full Remission?",
             "plt ≥ 100k, off all treatment")

arrow(c, TAPX, y_d2 - BH/2 - 8, TAPX, y_d_rem2 + 26)

# YES → remission oval
y_remis2 = y_d_rem2 - 75
oval(c, TAPX, y_remis2, 160, 32,
     "FULL REMISSION", fill_color=C_REMISSION)
arrow(c, TAPX, y_d_rem2 - 26, TAPX, y_remis2 + 16, label="YES")

# NO → relapse instruction
y_relapse2 = y_d_rem2 - 40
relapse_x = TAPX + 130
draw_box(c, relapse_x, y_relapse2 - 15, 155, 55,
    "RELAPSE MANAGEMENT",
    ["Mild: return to last effective dose",
     "Severe: restart full induction",
     "Re-give vincristine ± hIVIg (if not prev. used)",
     "Future tapers: more gradual",
     "Consider lifelong maintenance therapy"],
    C_REFRACTORY, title_size=7.5, body_size=6.2, r=5)
arrow(c, TAPX + 87, y_d_rem2, relapse_x - 77, y_relapse2 - 15 + 55/2,
      label="NO")

# NO → second line
arrow(c, MX, y_d2 - 30, MX, y_second + BH2/2, label="NO")

# ─────────────────────────────────────────────────────────────────────────
# ROW 5 – Second-line header
# ─────────────────────────────────────────────────────────────────────────
draw_box(c, MX, y_second, BW, 38,
    "ADD SECOND-LINE IMMUNOSUPPRESSANT",
    ["(Choose ONE based on clinician preference / patient factors)",
     "Onset 2–4 weeks – start early if anticipated"],
    C_SECOND, title_size=8, body_size=6.8, r=6)

arrow(c, MX, y_second - 19, MX, y_opts + BH2/2)

# ─────────────────────────────────────────────────────────────────────────
# ROW 6 – Four second-line option boxes
# ─────────────────────────────────────────────────────────────────────────
opt_w = 148
opt_h = 80
opt_gap = 12
n_opts = 4
total_w = n_opts * opt_w + (n_opts - 1) * opt_gap
opt_x0 = MX - total_w / 2 + opt_w / 2

opts = [
    ("AZATHIOPRINE\n(most common)",
     ["2 mg/kg/day PO × 2-4 wks",
      "then q48h (every other day)",
      "Onset: 2-4 weeks",
      "Monitor: CBC + LFTs q1-2 wks",
      "S/E: myelosuppression,",
      "hepatotoxicity, pancreatitis"]),
    ("CYCLOSPORINE\n(modified)",
     ["5 mg/kg PO q12-24h",
      "Trough target 200-400 ng/mL",
      "Delay several days post-vincristine",
      "S/E: vomiting, diarrhoea,",
      "gingival hyperplasia,",
      "opportunistic infections"]),
    ("MYCOPHENOLATE\nMOFETIL (MMF)",
     ["10-15 mg/kg PO q12h",
      "Alternative if azathioprine",
      "not tolerated",
      "S/E: GI upset (diarrhoea),",
      "bone marrow suppression",
      ""]),
    ("LEFLUNOMIDE",
     ["2-4 mg/kg/day PO",
      "Once daily",
      "Use when other options failed",
      "or not tolerated",
      "S/E: hepatotoxicity,",
      "bone marrow suppression"]),
]

for i, (title_raw, lines) in enumerate(opts):
    title = title_raw.replace("\n", " ")
    ox = opt_x0 + i * (opt_w + opt_gap)
    draw_box(c, ox, y_opts, opt_w, opt_h, title, lines,
             C_SECOND, title_size=7, body_size=6.2, r=5)
    # small arrow from header to each box
    arrow(c, opt_x0 + i*(opt_w+opt_gap), y_second - 19,
              opt_x0 + i*(opt_w+opt_gap), y_opts + opt_h/2,
          color=HexColor("#1565C0"), lw=0.8)

arrow(c, MX, y_opts - opt_h/2, MX, y_d3 + 30)

# ─────────────────────────────────────────────────────────────────────────
# ROW 7 – DIAMOND 3: Complete response at 2 weeks?
# ─────────────────────────────────────────────────────────────────────────
draw_diamond(c, MX, y_d3, 255, 60,
             "Complete Response at 2 Weeks?",
             "plt ≥ 100,000/µL, no bleeding")

# YES → right (join taper track)
arrow(c, MX + 127, y_d3, TAPX - 82, y_d2 - 30,
      label="YES", color=HexColor("#27AE60"))
# join taper box
arrow(c, TAPX, y_d2 - BH/2 - 3, TAPX, y_d2 - BH/2 - 8,
      color=HexColor("#27AE60"), lw=0.8)

# NO → refractory
arrow(c, MX, y_d3 - 30, MX, y_refrac + BH/2, label="NO")

# ─────────────────────────────────────────────────────────────────────────
# ROW 8 – Refractory
# ─────────────────────────────────────────────────────────────────────────
draw_box(c, MX, y_refrac, BW + 40, BH + 20,
    "REFRACTORY MEASURES",
    ["Reassess diagnosis – rule out secondary causes",
     "Splenectomy (removes site of plt destruction)",
     "Danazol 5-10 mg/kg PO q12h (slow onset, weeks-months)",
     "Thrombopoietin receptor agonist (eltrombopag / romiplostim)",
     "Cyclophosphamide 50 mg/m² PO days 1-4/wk (max 4-5 mo)"],
    C_REFRACTORY, title_size=8, body_size=6.5, r=6)

arrow(c, MX, y_refrac - BH/2 - 10, MX, y_end + 18)

# END oval
oval(c, MX, y_end, 200, 32,
     "Reassess & Individualise Care", fill_color=HexColor("#2C3E50"))

# ─────────────────────────────────────────────────────────────────────────
# ABCB1 / MDR1 caution note
# ─────────────────────────────────────────────────────────────────────────
note_x = 22
note_y = y_d1 - 10
c.setFillColor(HexColor("#FFF9C4"))
c.setStrokeColor(HexColor("#F5A623"))
c.setLineWidth(1)
c.roundRect(note_x, note_y - 55, 145, 60, 4, fill=1, stroke=1)
c.setFillColor(HexColor("#7B3F00"))
c.setFont("Helvetica-Bold", 7.5)
c.drawString(note_x + 5, note_y - 8, "⚠ ABCB1 / MDR1 BREEDS")
c.setFont("Helvetica", 6.5)
for i, line in enumerate([
    "Collies, Australian Shepherds,",
    "Shetland Sheepdogs, Border Collies",
    "→ Use CAUTION with vincristine",
    "→ Consider genetic testing",
    "→ Reduce dose or avoid if mutant"
]):
    c.drawString(note_x + 5, note_y - 20 - i * 9, line)

# ─────────────────────────────────────────────────────────────────────────
# RESPONSE CRITERIA side note
# ─────────────────────────────────────────────────────────────────────────
rc_x = 22
rc_y = y_d3 + 50
c.setFillColor(HexColor("#E3F2FD"))
c.setStrokeColor(HexColor("#1565C0"))
c.setLineWidth(1)
c.roundRect(rc_x, rc_y - 75, 155, 82, 4, fill=1, stroke=1)
c.setFillColor(HexColor("#0D2B5C"))
c.setFont("Helvetica-Bold", 7.5)
c.drawString(rc_x + 5, rc_y - 10, "RESPONSE CRITERIA")
c.setFont("Helvetica", 6.5)
rows = [
    ("No response:",   "plt <30k or bleeding at 2 wks"),
    ("Partial resp.:", "plt 30-100k, >2× baseline,"),
    ("",               "no bleeding"),
    ("Complete:",      "plt ≥100k, no bleeding"),
    ("Full remission:","plt ≥100k, off all treatment"),
]
yy = rc_y - 23
for label, val in rows:
    if label:
        c.setFont("Helvetica-Bold", 6.5)
        c.drawString(rc_x + 5, yy, label)
        c.setFont("Helvetica", 6.5)
        c.drawString(rc_x + 62, yy, val)
    else:
        c.setFont("Helvetica", 6.5)
        c.drawString(rc_x + 62, yy, val)
    yy -= 10

# ─────────────────────────────────────────────────────────────────────────
# SAVE
# ─────────────────────────────────────────────────────────────────────────
c.save()
print(f"Saved to {OUTPUT}")

Running Command

cd /tmp/workspace/imtp-flowchart && python create_flowchart.py 2>&1

Running Command

python3 -c " from pypdf import PdfReader r = PdfReader('/tmp/workspace/imtp-flowchart/IMTP_Treatment_Flowchart.pdf') print(f'Pages: {len(r.pages)}') print(f'Size: {r.pages[0].mediabox}') import os print(f'File size: {os.path.getsize(\"/tmp/workspace/imtp-flowchart/IMTP_Treatment_Flowchart.pdf\")/1024:.1f} KB') "

Your flowchart PDF is ready:

IMTP Treatment Flowchart

PDF Document · PDF

What's included in the flowchart (A3 landscape, single page):

START - Dog with suspected IMTP
Emergency Stabilisation - IV fluids, blood products, doxycycline, discontinue NSAIDs
Decision Diamond 1 - Clinically significant bleeding or platelet count <20,000/µL?
- YES branch - Adjunctive therapy box: Vincristine 0.02 mg/kg IV (single dose) OR hIVIg 0.5-1.5 g/kg IV
- Both branches merge into first-line treatment
First-Line: Glucocorticoids - Prednisolone 2-4 mg/kg/day PO (with dexamethasone IV alternative)
Decision Diamond 2 - Response at Day 5-7?
- YES - Taper protocol box (20-25% every 2-4 weeks) → Full remission diamond
- NO - Add second-line drug (four option boxes: Azathioprine, Cyclosporine, MMF, Leflunomide - each with full dosing)
Decision Diamond 3 - Complete response at 2 weeks? → links back to taper or down to refractory
Refractory Measures - Splenectomy, Danazol, TPO agonists, Cyclophosphamide
Monitoring panel (purple, right side) with CBC and lab monitoring schedule
Taper/Relapse management boxes
Side notes - ABCB1/MDR1 breed caution box and Response Criteria reference panel
Colour-coded legend for all box types

This is a shared conversation. Sign in to Orris to start your own chat.