vomiting cat and ex-lap

Re: vomiting cat and ex-lap

Rob Loxley — Wed, 19 Dec 2012 15:47:02 GMT

[quote user="Mark Holmes"]Seriously, when you fine a large abdominal mass in an anorexic elderly cat how often is it not lymphoma? I believe I have once had a mast cell tumour and the occasional adenocarcinoma, although they tend not to be so big. The margin of error is pretty small and you have you question whether the outcome is improved.[/quote]

I agree most seem to be, but we see a fair few adenocarcinomas and a few FIP granulomas. For the latter a diagnosis might push you to earlier euthanasia, for the former surgery might be curative. If it's a large mass then I'd aim initially to image/FNA and send the slides to a good cytopathologist, but as I said if funds preclude then I'm not going to spare it the preds.

Re: vomiting cat and ex-lap

scatty — Wed, 19 Dec 2012 14:52:13 GMT

Mark, from what I've read (and I by no means have a lot of experience as this is only the 2nd lymphoma I've ex-lapped), leukeran is only documented as being of use in protocols for small cell lymphoma like Raj said. I think that if you can palpate a lump it is more likely to be high grade. I've looked and I can't see any studies that show that leukeran can help HGL. I wonder why this is - whether because it is an alkylating agent it is not as good for cancers with a higher cell turnover rate? I don't think giving leukeran in this instance would be going against the principle of 'Do no harm' but I guess we can't prove if it works either. It would be an interesting study to compare cats given preds with HGL and cats given preds and leukeran to see if there is any advantage of adding it in. I think that's why Rob is saying he would just use the preds if the owner is not interested in ex-lap. There aren't lots of studies about cats in this field so that makes our life harder but I do value these sort of discussions in forums otherwise it's hard to know what other people do (as the numbers of cats in studies is small).

Anna

Re: vomiting cat and ex-lap

Mark Holmes — Wed, 19 Dec 2012 13:41:32 GMT

[quote user="robloxley"]

[quote user="Mark Holmes"]So simply putting a cat with a large abdominal mass on pred and leukeran off the cuff, wouldn't bee too far wrong then[/quote]

Without any further investigations you can't know whether it's neoplastic or not, or whether it might be a neoplasm that surgery could cure. But if the only other option is PTS then I'd try some preds.

[/quote]

Seriously, when you fine a large abdominal mass in an anorexic elderly cat how often is it not lymphoma? I believe I have once had a mast cell tumour and the occasional adenocarcinoma, although they tend not to be so big. The margin of error is pretty small and you have you question whether the outcome is improved.

Re: vomiting cat and ex-lap

Rob Loxley — Wed, 19 Dec 2012 13:19:53 GMT

[quote user="Mark Holmes"]So simply putting a cat with a large abdominal mass on pred and leukeran off the cuff, wouldn't bee too far wrong then[/quote]

Re: vomiting cat and ex-lap

Mark Holmes — Wed, 19 Dec 2012 06:54:00 GMT

So simply putting a cat with a large abdominal mass on pred and leukeran off the cuff, wouldn't bee too far wrong then.

Re: vomiting cat and ex-lap

scatty — Tue, 18 Dec 2012 23:15:01 GMT

[quote user="robloxley"]

When the Specialists can't agree I assume that's because nobody really knows...

[/quote]

I found this in a recent In Practice article by Gerry Polton,

' In feline lymphomas there is no clear indication from the veterinary literature about which treatment approach achieves a superior outcome. Attempts to examine the published data in more detail only cloud this matter further'.

hehe this couldn't be more true.

Re: vomiting cat and ex-lap

scatty — Tue, 18 Dec 2012 19:46:19 GMT

I think that's a very fair point! :)

Re: vomiting cat and ex-lap

Rob Loxley — Tue, 18 Dec 2012 17:31:55 GMT

When the Specialists can't agree I assume that's because nobody really knows...

Re: vomiting cat and ex-lap

scatty — Tue, 18 Dec 2012 10:25:20 GMT

Hi everyone, thanks for all of your input about chemo protocols;

Following all of your suggestions, this got me thinking about the different overall doses for different protocols so I looked at a paper which detailed chemo for SML in cats at the university of Madison-Wisconsin.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092124/

and then contacted Gerry Poulton from North Downs Referrals to see what he would use. He would use 5 mg pred sid and 4 mg leukeran once a fortnight which equates to the 20 mg/metre squared q 2 weeks used in this protocol (which obviously works out overall quite a bit less than 2 mg 72 hrs). He thinks there is no need to be so aggressive in treating SML. Very interesting view from the specialist front. Sounds like people have used much higher doses in practice to no ill effect though. Interesting to see what everyone uses though! The cat did well over the wknd and his stiches come out this fri so I'll be starting him off on treatment just before xmas.

Anna

Re: vomiting cat and ex-lap

Kate Richardson — Mon, 17 Dec 2012 15:35:33 GMT

[quote user="Mark Hedberg"]

Congrats :) hanging around here, you should get plenty of practice dealing with small children *hides*

[/quote]

He he Thanks Mark. Hope all goes well for you and your wife, keep us posted

Re: vomiting cat and ex-lap

Mark Hedberg — Mon, 17 Dec 2012 15:27:23 GMT

[quote user="james herriot lied"]

[quote user="Mark Hedberg"]

hanging around here, you should get plenty of practice dealing with small children *hides*

[/quote]

Sez 'Babyface' Hedberg.......

Are you sure you're 6'5", Mark?

[/quote]

Only when I slouch (and my wife's delivery date for child #2 is in 10 days time...)

Re: vomiting cat and ex-lap

james herriot lied — Mon, 17 Dec 2012 15:16:11 GMT

[quote user="Mark Hedberg"]

hanging around here, you should get plenty of practice dealing with small children *hides*

[/quote]

Sez 'Babyface' Hedberg.......

Are you sure you're 6'5", Mark?

Re: vomiting cat and ex-lap

Mark Hedberg — Mon, 17 Dec 2012 15:08:15 GMT

Congrats :) hanging around here, you should get plenty of practice dealing with small children *hides*

Re: vomiting cat and ex-lap

Kate Richardson — Mon, 17 Dec 2012 14:27:43 GMT

Boys boys, you are both on the same side of the fence from where I am sitting, just coming at it from different angles and I agree with what both of you are saying. I get the feeling you work with very different client cohorts....?

In any case you are dealing with, all the investigations and treatment options should be discussed with the client and they should be assisted to make an informed decision about how to proceed further. As long as they accept the short comings of their choice and more importantly it doesn't mean the animal is going to suffer then that choice is their choice. It is very hard as a vet sometimes to keep one's own feelings about investigative procedures and treatment regimes to one's self and remain completely unbiased. You also do get to know your clients and their pets and they come to us for advice about what we think is best for their circumstances and like it or not we sometimes have to make judgements and decisions on their behalf; we still have to present all the information but we than have to interpret their responses to that information and help guide them to making the right decision for them, as individuals.

In the real world life gets in the way of being 100% compliant with everything we advise doing. Tablets get missed or found on the floor later, the cat disappears, the cat doesn't want his tablets today, the children are sick and need to go to the doctors etc etc. Add to that the financial aspect. It is wonderful when you get a client who puts in 100% effort to do as you advise, but in reality, how many actually do. But in most cases they do the best they can and we have to support them in doing so and accept that reality. And be honest about when it is simply kinder not to treat. Just because we can, doesn't mean we should. I sometimes feel people feel pressurized or guilty and take on an investigation or treatment regime, when actually they really want us to offer them euthanasia, but they aren't offered this and aren't brave enough for want of a better phrase, to suggest it themselves. I find most people appreciate it when you are brutally honest and frank with them, and it is a relief when you offer that option and they didn't have to suggest it themselves for want of being judged as cruel. (I'm not suggesting the case here warrants this, this is more just generalisation).

[quote user="Mark Holmes"]I'm not convinced enough people consider the stress involved in treatment[/quote] I would agree with you Mark, it is too easy sometimes to just prescribe more pills without really sitting down with the owner and asking them how are they coping. I'm probably guilty of this from time to time too. I think there is often a time factor involved here- as Rajat pointed out [quote user="Rajat"]sadly a 10 minute consult ain't enough [/quote] and at some practices, it is very difficult to take this time. Sometimes it is just better and simpler and less stressful to do the bare minimum or nothing at all.

Sorry for rambling on, have too much time on my hands these days being 7 months pregnant and working part time now!

Re: vomiting cat and ex-lap

Rajat — Mon, 17 Dec 2012 12:48:45 GMT

[quote user="robloxley"]

How soon after full thickness gut biopsy do people start pred/chloramb, thinking about dehiscence...

[/quote]

For me, it is 5 days minimum...

Re: vomiting cat and ex-lap

Rob Loxley — Mon, 17 Dec 2012 12:45:43 GMT

How soon after full thickness gut biopsy do people start pred/chloramb, thinking about dehiscence...

Re: vomiting cat and ex-lap

Mark Holmes — Mon, 17 Dec 2012 10:08:26 GMT

[quote user="Hannah Wynne Richards"]

I'm 100 % with Rajat None of us have any moral or legal right whatsoever to make judgements about how much money/time/effort a client is prepared to commit to save an animal

Wynne

[/quote]

I don't know where the assumption has come from that non of this is discussed. A workup is always offered. But if an owner is reulctant to go for a work up (common in an older cat) and you have a tangerine sized mid abdominal mass and an anorexic cat it is hardly a stretch to come up with a likely diagnosis. My point was simply that pred and leukeran works great in alot of cases.

Raj seems to have assumed that I simply put cats onto medication. Why would anyone do that?

Re: vomiting cat and ex-lap

Hannah Wynne Richards — Mon, 17 Dec 2012 10:02:35 GMT

I'm 100 % with Rajat None of us have any moral or legal right whatsoever to make judgements about how much money/time/effort a client is prepared to commit to save an animal

Wynne

Re: vomiting cat and ex-lap

Mark Holmes — Sun, 16 Dec 2012 23:18:27 GMT

Just to be clear the stars are not due to me

Re: vomiting cat and ex-lap

Rajat — Sun, 16 Dec 2012 20:36:45 GMT

This is getting stuck in us trying to interpret what 'he said she said' so this is my last post

You did say 'a lot' when referring to cats with abdo masses who you'd put on this protocol. Now its a good number but 'not most'. But it is a 'handful a year'. Which is equal to how many wheel-barrows worth exactly?

I know what you're saying, kind of...but very confused about whether you treat the minority of your elderly feline patients who present this way or the majority. Or somewhere in between.

[quote user="Mark Holmes"] My point was its one thing to expect a client to medicate a difficult cat for a short finite period of time but several times a day indefinitely is quite another[/quote]

I agree- a difficult cat yes. If the cat is an evil shit or runs and hides for a week every time it is brought to the vet the decision might be a bit easier and quicker to make re chemo or not!

But to put all or most or a majority (or a handful?!!) of our patients in this category without going through options with our clients is not the right way. It's all too easy to influence the client based on our preconceived notions of what may or may not be accepted by the pet and/or the client. I think these cases take time, to go through everything with the client in detail- sadly a 10 minute consult ain't enough - sometimes a bit of consultation with family etc and then another chat next day or 2 is needed- and then an informed decision can be reached with vet and owner as a team. If this is what you do, and all your clients choose a chemo protocol based on your guess, fair enough.

Additionally, you do realize that the pred and leukeran protocol for these cases involves more pilling by the client than the chemo protocols involved? Making yours a null arguement about it being more involved for the client - you previously argued it was more stress for the cat... so I'm not sure which point is really being debated here.

As for the stress - some cats take pills easy peasy. Some need them hiding in cheese. or meat or marmite. Or compound them or use a different version eg liquid... I do everything poss to make it easy for my clients to medicate their cats without stress. Obviously we fail sometimes, but what I could not do is say oh no its too stressful for you and your pet here have some treatment which I know is not as good as it could be without at least trying the options.

*Wearing my one star with pride*

Raj

Re: vomiting cat and ex-lap

Mark Holmes — Sun, 16 Dec 2012 18:56:55 GMT

Don't assume that "a good number" = most. A good number amounts to a handful a year, but not the majority. My reference to cardiac medication was in full knowledge of the pharmacology. My point was its one thing to expect a client to medicate a difficult cat for a short finite period of time but several times a day indefinitely is quite another and I would comfortably take account of this and use simply dimazon. Accepting the expected consequences. I am not convinced everyone does remember the failures and I'm not convinced enough people consider the stress involved in treatment. The end does not justify the means.

Re: vomiting cat and ex-lap

Rajat — Sun, 16 Dec 2012 16:59:57 GMT

[quote user="Mark Holmes"]Now Raj, if you read my post on the subject I said that I didn't advocate every patient. I have excised intestinal masses, biopsied bowel and taken plenty of guided FNAs. But I don't forget that the most important experience in all this is the cats, and most older cats seem to prefer NOT being at the vets all the time. Not being constantly poked bled, restrained and the like. Similarly most of my clients at least seem to be very happy with a "Shall we try and keep this simple even if it costs us a few months longevity." To be honest I use the same reasoning when putting difficult tableting cats on multiple medications. I regularly will say that there is a world of difference in restraining a cat for tablets of a few days eg a course of antibiotics and doing it several times daily, indefinitely eg Cardiac medications. I have has loads of cars simply on dimazon injections when they probably should have been on fortekor and plavix. Don't forget that a 25% success rate still means that 3 out of 4 animals experienced the distress of any intervention for nothing.

[/quote]

I did read your post Mark- and you said a lot of cats with abdo masses benefit from preds and leukeran. You didn't say you were working these cats up. This is what I cannot agree with. Ok so later I mistakenly said 'all cats' when talking about chemo or not - happy to retract and replace with a lot of ( I assume 'a lot' means 'most' of these cases that you see ?)

I appreciate that the cats experience is v important. I think we all should consider that and the individual cat and I think we do. I don't like to impose my beliefs on the owner though (not saying you do) and find when presented with facts and experience the majority of owners do opt for chemo (and I give them options of which chemo protocol too to a certain extent) and are happy to proceed along these lines. Cats that are very stressed by visits or where owners perception is such and/or require sedation are in the minority in my experience. I don't think they are good candidates for intensive chemo protocols but I don't think they are absolute no-nos. But they are in the minority rather than the majority.

As for older cats not liking being at the vets weekly - honestly I can't think of any age group of cats that are not stressed by vet visits.

Hmm dimazon instead of plavix/fortekor? I think these drugs do different things but I could be mistaken..

And lastly what disease process does a 25% success rate refer to? I am familiar with the concept of arithemtic arithmetic (100-25=75!) but I do struggle with the spelling sometimes..!

Re: vomiting cat and ex-lap

Andrew Kent — Sun, 16 Dec 2012 16:50:11 GMT

[quote user="Rajat"]

Cheers Andy, I have not however had any issues with this protocol in small cats , used starting dose q 48 hours in approx 10 cats now...but Pred is going to do the donkey work to start anyways whether we starts chlorambucil q 48 or 72 hours eh

I see your point re 'there is pred on board so why bother with diet ' - I used to do that too, however if we believe ongoing antigenic stimulation may lead to SCL from IBD, and diet plays a significant role in that antigenjic stimulation then it makes sense to get rid of some/all of that stimulation. Having seen what my cat who takes pred e.o.d for her IBD does when I try different diets from the one that suits her best I reckon it is worth it. It's a bit like saying I'm taking anti histamines so why avoid pollen IMHO altho of course the link between diet and IBD is still tenacious and we are guessing what may have triggered the neoplasia int he first place so this has to be a soft recommendation!

Cheers

Raj

[/quote] There is a difference between your cat which has a degree of diet responsive enteritis and is managed by diet and an anti-inflammatory dose of pred and a cat with lymphoma which will be on combination immunosuppressive for the rest of its life. I think in these cases the more things you throw into the mix the worse the compliance is likely to be. Plus we're treating a terminal illness so I would let it eat what it wants!

Re: vomiting cat and ex-lap

Mark Holmes — Sun, 16 Dec 2012 16:36:27 GMT

Now Raj, if you read my post on the subject I said that I didn't advocate every patient. I have excised intestinal masses, biopsied bowel and taken plenty of guided FNAs. But I don't forget that the most important experience in all this is the cats, and most older cats seem to prefer NOT being at the vets all the time. Not being constantly poked bled, restrained and the like. Similarly most of my clients at least seem to be very happy with a "Shall we try and keep this simple even if it costs us a few months longevity." To be honest I use the same reasoning when putting difficult tableting cats on multiple medications. I regularly will say that there is a world of difference in restraining a cat for tablets of a few days eg a course of antibiotics and doing it several times daily, indefinitely eg Cardiac medications. I have had loads of cats simply on dimazon injections when they probably should have been on fortekor and plavix. Don't forget that a 25% success rate still means that 3 out of 4 animals experienced the distress of any intervention for nothing.

Re: vomiting cat and ex-lap

Rajat — Sun, 16 Dec 2012 16:04:14 GMT

[quote user="Mark Holmes"]Raj, I think you must see a very different cohort of clients to me[/quote]

Maybe I do.

[quote user="Mark Holmes"] think there is much to be said about keeping end of life treatment simple and hands off given the distress to the cat that regular bleeding and iv meds entails.[/quote]

If chemo gives a year or bit less of good QOL I don't see why we need to ring the 'this is the end of life' bell at the start and give up. I have seen the odd animal cured of lymphoma by chemo too - 2 in the last 5 years. Tho this is obviously not the goal with chemo - we are aiming for quality not quantity of life but its a bonus. I don't advocate chemotherapy for every animal with neoplasia - the right owner and right pet is needed but I don't believe in blanket pred and leukeran for every older cat with an abdo mass either. I feel that is poor medicine.

Are you familiar with the literature on owner perceptions on QOL with chemo in cats and dogs?

Oh and I reckon I get an answer in 70% of US guided aspirates. Easier not to hit intestinal lumen that way (tho not impossible!)

[quote user="Mark Holmes"] I also struggle with "That kind of owner" remark.[/quote]

What I meant was the kind of owner who thinks any intervention is cruel and will only want 'some pils' to sort out the cat's obviously major problem.

Actually I was giving you the benefit of doubt - Maybe I should have said that kind of vet - i.e. one who thinks any intervention other than dispensing chemo drugs without a workup at this stage is correct - no offense - I know some who would do the same who are good friends. And I tell them to their face what I think.