dog not tolerating lymphoma chemo

Re: dog not tolerating lymphoma chemo

Anthony Todd — Wed, 15 Apr 2015 17:48:10 GMT

[quote user="Virginia Campbell"]We stopped the pred. The D+ cleared up. We restarted the vincristine. He was fine. We restarted the pred. He got explosive D+ again. We stopped the pred. The D+ cleared up. [/quote]

Fair enough, very hard to dispute that. Just wonder why, on it's own it's fine?

[quote user="Virginia Campbell"]I'm surprised you've never had D+ as a SE of steroids at high doses. [/quote]

Don't think I ever did, but this is with a high, but therapeutic, single dose, not the current continuous low dose which does nothing really, IMHO.

Re: dog not tolerating lymphoma chemo

Virginia Campbell — Wed, 15 Apr 2015 16:57:59 GMT

[quote user="Gerry Henry"]thanks Gerry for a very helpful and concise post[/quote]

Yes! It contained all the information I wanted to know. I spoke to the owners yesterday. The dog is doing well though it took over a week for his stools and demeanour to return completely to normal. I think they've become scared of anything that could be described as a chemo drug, or has diarrhoea listed in the SEs - which, as Anthony pointed out, is pretty much everything. I'm not surprised, as their previously bouncy normal-poo'd dog had two nasty bouts which knocked him back and took a while to clear. They're giving him turmeric powder now and I can't see any harm in that.

I discussed chlorambucil and left them to think about it. It's a low grade lymphoma anyway so no harm in letting dog and owners "rest" for a bit before doing anything else. I'll ring them in a week or two just to check in and see how the dog is doing.

I think in hindsight I could have managed this case better. The owners had big reservations about chemo to begin with so perhaps I should have opted for Leukeran at home as my first choice, got him settled on that for a couple of weeks then added pred, instead of charging in with the vincristine, cyclophosphamide and pred doses blazing all at once. I suppose I thought that being a relatively young healthy dog, SEs would be less likely. Oops. Or at least given up on my protocol after the first episode or D+ and switched to Leukeran then before the owners got cheesed off with the whole chemo idea all together. Ah well. Live and learn. Speaking of which, that paper abstract Gerry put up is interesting - I missed that when it came out. Every day's a school day....

Thanks all, and [quote user="Gerry Henry"]one of the really good things about this site is the willingness of specialists to share their knowledge [/quote] as always - still loving vetsurgeon.org!

Re: dog not tolerating lymphoma chemo

Virginia Campbell — Wed, 15 Apr 2015 16:20:01 GMT

[quote user="Anthony Todd"]Why is it that pred ALWAYS gets blamed when side effects or any other ill-effect occurs, even when there are a multiplicity of possibilities, not including the dietary indiscretion mentioned by one poster, which would be the first thing I'd look at ,bearing in mind the breed and the possible polyphagia of anything on steroids.[/quote]

Well, he got vincristine, a fair whack of cyclophospamide and pred. He got explosive D+.

We stopped the pred. The D+ cleared up. We restarted the vincristine. He was fine. We restarted the pred. He got explosive D+ again. We stopped the pred. The D+ cleared up.

Now, as you point out, it may not be a direct effect of the pred. He might have scavenged....though the owner made no mention of him being really polyphagic on pred. I don't care if it was an indirect effect though - I'm not putting a muzzle on the poor sod or strapping it to its owner on walks for the forseeable future. He's a big lively dog and needs to enjoy life.

Similarly, it might be bacterial overgrowth due to immune suppression. If this is the case, then my chemo protocol is too unselective in this dog - it's squashing bits of his immune system too hard, and not making enough of a dent in the lymphoma itself.

I'm surprised you've never had D+ as a SE of steroids at high doses. I've had a couple of IMHA dogs get some D+, though usually when they'd been on pred for a few weeks. Better than being dead, obviously, and in those cases it wasn't too bad - but this dog's episodes have been severe enough to warrant taking him off pred altogether.

I love pred. Just not for this dog.

Re: dog not tolerating lymphoma chemo

Anthony Todd — Wed, 15 Apr 2015 16:17:27 GMT

[quote user="Kate Richardson"]is it possible the pred was the straw that broke the camel's back in this case? However[/quote]

Why not one of the other drugs!?

"Never in the field of vet. pharmacology has etc....... pred"

If Cameron loses the election I'll bet someone here blames it on poor old pred!

Re: dog not tolerating lymphoma chemo

Kate Richardson — Wed, 15 Apr 2015 15:35:36 GMT

[quote user="Anthony Todd"]

Why is it that pred ALWAYS gets blamed when side effects or any other ill-effect occurs, even when there are a multiplicity of possibilities, not including the dietary indiscretion mentioned by one poster, which would be the first thing I'd look at ,bearing in mind the breed and the possible polyphagia of anything on steroids.

Google all of the drugs mentioned in the entire thread and they ALL list diarrhoea [some only "black tarry stools"] as a side effect.

As a rampant user of steroids in "high" doses,, although not continuously, I can't say D+ was ever a side effect; polyuria for sure, but no diarrhoea.

[/quote]

For once I sort of agree with you Anthony Diarrhoea is a common side effect of chemotherapy drugs- is it possible the pred was the straw that broke the camel's back in this case? However

[quote user="Gerry Polton"]

In conclusion, prednisolone, as part of a multidrug chemotherapy protocol, has no additional effect on treatment results and can be omitted from first-line multidrug protocols used for the treatment of canine lymphoma.

[/quote]

this is interesting, and if it is the straw and the dog can be managed without the pred then there is no point adding it. (obviously not on the same protocol if it's not working though as in this case)

Re: dog not tolerating lymphoma chemo

Anthony Todd — Wed, 15 Apr 2015 08:58:55 GMT

[quote user="John Flynn"]I'm not saying it's to blame,[/quote]

Google all of the drugs mentioned in the entire thread and they ALL list diarrhoea [some only "black tarry stools"] as a side effect.

As a rampant user of steroids in "high" doses,, although not continuously, I can't say D+ was ever a side effect; polyuria for sure, but no diarrhoea.

Interestingly one site mentions dexamethasone, rather than pred as a treatment, which is worthy of expert comment [not by me] as another steroid may possibly be more effective.

Re: dog not tolerating lymphoma chemo

Christopher Saul — Tue, 14 Apr 2015 12:52:49 GMT

+1 for chlorambucil here. Generally very well tolerated....

Re: dog not tolerating lymphoma chemo

Martin Atkinson — Tue, 14 Apr 2015 10:36:02 GMT

[quote user="Gerry Henry"]one of the really good things about this site is the willingness of specialists to share their knowledge [/quote]+1 for that. I was going to suggest Chlorambucil to the OP but only because of previous advise from Gerry et al. So thanks again.

Re: dog not tolerating lymphoma chemo

Gerry Henry — Tue, 14 Apr 2015 08:29:16 GMT

Not my case but thanks Gerry for a very helpful and concise post, one of the really good things about this site is the willingness of specialists to share their knowledge with 1stOp practitioners like myself.

Re: dog not tolerating lymphoma chemo

Gerry Polton — Tue, 14 Apr 2015 08:24:20 GMT

I would be pretty convinced it's the steroids that your patient is struggling with. To answer John's question, see below the abstract of the paper you would want to read.

It seems you have two problems though. One is that the lymphoma hasn't gone away. The other is that something appears to have induced an unpleasant diarrhoea. Of these, the failure to achieve complete remission is the most significant in my opinion. Since the original diagnosis was confused with reactive hyperplasia, I would conclude that you have a low grade lymphoma and for that reason I would definitely consider treatment with chlorambucil (minus the steroids). I think it will also suit this client better given the anxieties they will naturally have about intravenous chemo. In a labradoodle you are probably looking at 4mg or 6mg once every second day. I would go for 4mg for the first two weeks unless this is a very big dog (>36kg) in which case go for 6mg from the start. Be aware that chlorambucil can induce diarrhoea too. (And be aware that Labradoodles can get diarrhoea for other reasons, eg steroid induced scavenging and 'dietary indiscretion'.)

Gerry

Vet J. 2013 Sep;197(3):656-61. doi: 10.1016/j.tvjl.2013.04.022. Epub 2013 Jun 6.

Prednisolone inclusion in a first-line multidrug cytostatic protocol for the treatment of canine lymphoma does not affect therapy results.

Zandvliet M1, Rutteman GR, Teske E.

Author information

Abstract

Chemotherapy protocols for canine lymphoma include the routine use of glucocorticoids for their lympholytic effect. However, glucocorticoids are associated with side effects (e.g. polyphagia, polyuria, and weight gain), limit the use of non-steroidal anti-inflammatory drugs, and can induce drug transporter expression that could lead to drug resistance. Despite these negative effects, there are no data to support the use of glucocorticoids as part of a multidrug chemotherapy protocol for the treatment of canine lymphoma. A prospective, randomized clinical trial was conducted in 81 dogs with multicentric lymphoma and no history of recent glucocorticoid use. All dogs were staged and treated with the same chemotherapy protocol (L-asparaginase, cyclophosphamide, doxorubicin, vincristine, and prednisolone) with half of the dogs receiving prednisolone. Both treatment groups were similar with respect to demographics, immunophenotype, and clinical stage, except for a higher number of substage b patients in the prednisolone group (5 vs. 14; P=0.015). Treatment results obtained with the initial treatment (complete response rate 75%, disease-free period 176 days) and rescue treatment (complete response rate 45%, disease-free period 133 days), overall survival (283 days) and adverse events (number and grade) were similar for both groups. In conclusion, prednisolone, as part of a multidrug chemotherapy protocol, has no additional effect on treatment results and can be omitted from first-line multidrug protocols used for the treatment of canine lymphoma.

Re: dog not tolerating lymphoma chemo

John Flynn — Mon, 13 Apr 2015 21:28:35 GMT

I'm not saying it's to blame, but to be controversial, I'm yet to be personally convinced that the pred is an essential (or even useful) adjunct to this sort of chemo protocol - the data may be out there?

I know very little re chemo options, but doxorubicin always seems to feature highly in such discussions.

Could the D+ be from immunosuppresion and GI bacterial overgrowth post-chemo?