Know anything about leukeran and anemia? or cyclosporine?

Shaikha was put on leukeran about 10 days ago for management of her pancreatitis and IBD since steroids made her diabetic. My vet hadn't used it previously but it was strongly recommended by TAMU's GI lab so we gave it a try. Unfortunately, Shaikha's HCT has dropped like a rock on it. She went from 35.6% prior to starting (taken a few weeks prior to beginning it) to 18.4% today. Obviously, this is not a good thing. I already have an anemic cat and we stress out his supply of donor cats keeping Tabriz alive with transfusions (Tabriz developed antibodies to epogen, so he is transfusion-dependent now).

My vet talked to Auburn this time and they recommended we stop leukeran altogether given the huge drop in PCV. What they suggested we do given that her diabetes is not controlled yet is to put her on cyclosporine instead.

Has anyone had leukeran cause this type of anemia and does it get better with time? I'm scared we've created a problem like Tabriz's. She is acting fine, incidentally. Her appetite is slightly down, but activity level, etc. is good and she certainly isn't acting like Tabriz did when he developed anemia. I wouldn't have guessed she even had a problem given her behavior, actually, and I'm pretty good at detecting when Tabriz's PCV has gone down enough that he's ready for another transfusion.

If anyone has used leukeran and had their cat develop anemia, I'd love some feedback. If you have used cyclosporine for IBD or pancreatitis, I'd love feedback about that as well. The bad thing is that I really think the leukeran was helping. I was finally able to stop painkillers a day ago, and she's not been able to get off them at all since we stopped the steroids.

Help! I'm really scared for her, and us. :sad:

 

Yes, leukeran can suppress the bone marrow which will lead to anemia.

Have you ever tried budesonide for the IBD?

 

My Mario was on 2 mg three days a week and never had a blood-work problem. He has small-cell intestinal lymphoma. Has the vet check for occult to help determine the cause of the anemia? Occult blood is blood that escapes via the GI tract into the feces. Does the vet know if the anemia is regenerative (blood cell being produced normally but dying too soon) or non-regenerative (not being produced fast enough). Because of the short time, ten days, internal bleeding is a possibility.

 

My vet hasn't used bedesonide before, but did ask about it at TAMU and they advised against it because Shaikha's diabetes was not controlled. In Shaikha's case, it isn't just IBD but also bad pancreatitis that's the problem. Her spec fPL keeps rising, even while on heavy doses of steroids. We haven't retested since beginning leukeran.

Do you know if the anemia will go away or does it tend to stay around? I'm panicking because Tabriz is transfusion dependent and managing two cats with that condition would be awful. I'm afraid I'm going to lose both of them. This is so unfair. :cry:

Will cyclosporine work for bad cases of pancreatitis and IBD? I read through Plumbs and it doesn't appear to have the same side effects as leukeran does, but it mentions only IBD, not pancreatitis. Auburn is recommending we put both Tabriz and Shaikha on it. They didn't recommend steroids because of her diabetes and because of Tabriz's CRF. I'm not sure if my vet asked about budesonide or not.

We do need to do something because she's been so bad off from the pancreatitis. Tabriz is also having big issues right now. Usually his pancreatitis flares for a week or so, but this time he's got a bad case of it for about the past month. I was afraid his poor condition was due to his liver and/or kidneys getting worse, but tests today actually show the ursodiol is working for his liver (big drop in ALT!). BUN rose, but creatinine fell slightly, but neither number is really bad. Phosphorus is also pretty decent. He does appear to have a UTI or possibly kidney infection as he's still got tons of white cells in his urine and was running a slight fever. We sent urine off for a culture and sensitivity.

I'm at my wits end right now. I think the reason I'm reacting so much is that both cats are so ill and I'm not doing so well myself, so the stress meter is off the scales. On a good note, though, I went out and bought some gluten-free Fancy Feast and Tabriz pigged out. Not the best food for his CRF but at this point I'm happy he's just eating anything.

 

Have you tried a low fat diet for the pancreatitis issues? Low fat was Boo's best friend.

Sorry so brief but I'm on my Blackberry at the moment.

 

Larry, I was wondering that myself on the way home, given the steep drop. I need to call the clinic and ask if there was another PCV done sooner than the records I have here, so I can better determine how long it was between tests. She's had several CBCs done prior to leukeran though and her PCV was always very normal (above 35% every time).

I will call the vet tomorrow to discuss more. It probably wouldn't hurt to put her on something like sucralfate just in case. I suppose it could also be that the pancreatitis has caused some bigger issues internally. Can IBD cause internal bleeding as well? Her stools look good though (not black), but I know that occult blood can also be invisible. I suppose I'll need to carry in some stool samples for both cats tomorrow. My vet was talking about that today, in fact, so maybe he was thinking along the same lines.

Thanks so much for your feedback.

 

From what I've read, fat seems to bother some cats but not others. I put her on a grain-free diet for her IBD and that has firmed up her stools nicely. I don't know if the Hills d/d duck and green pea she's been getting is low fat or not. I've tried to get her onto the canned variety entirely rather than dry, but am having mixed success. She'll eat it, but prefers dry. Given the IBD I don't want to give her too many different types of foods. I did buy some Fancy Feast today that is supposed to be low in carbs, but I'm not sure how low in fat it would be. I'm afraid if we change up her diet she'll get diarrhea again (am dealing that with my other pancreatitis cat right now).

What food did you feed to Boo?

 

Hi Wendy

I'm sorry to hear about her poor reaction to the Leukeran, that stinks

A few things: did you send a CBC out to the lab? This will give you a good picture of what the Leukeran has done. You can also add a reticulocyte count. As you probably know from your other guy, this can give info on whether or not she is trying to make new RBCs, and they are getting "lost" (through bleeding or destruction), or if she is not making new blood cells. One caveat is that it can take several days from the bleeding incident for a cat to have an increase in reticulocytes.

Did you do a blood chemistry today? GI bleeds are frequently accompanied by a spike in BUN (not creatinine).

I think you're right, though, this is probably the Leukeran suppressing her bone marrow. I am surprised that TAMU is so much against giving her steroids, since she tolerated them well and they worked well to control her IBD and pancreatitis (clinically, if not on paper). Cyclosporine is a tough drug that many animals don't tolerate well, so personally I'd be hesitant to use it if there was a familiar, well-tolerated alternative available. As I may have mentioned before, my cat developed DM from steroids and we just treated his DM. Eating and digesting food, and not being crippled with pancreatic pain are all important factors in the "quality of life" scale.

I remember your other post saying that this IBD stuff started around April? Given the relatively sudden onset and her symptoms, I'd consider doing biopsies if I were you. I wouldn't bother with endoscopy, but I'd certainly consider laparascopy. If she has (hopefully not) cancer, for example, we may be missing valuable treatment time here. I'd really consider it. I wish I had done this for my late cat; I didn't and his treatments were badly misdirected.

 

My cat Boomer had pancreatitis and IBD. He became diabetic because of prednisone so we switched him to budesonide which is a steroid, but not the same type. I was able to get him OTJ while on budesonide.

 

This is just personal and anecdotal, so take that into consideration, but Astrophe was given cyclosporine for her hemolytic anaemia, and it caused pancreatitis. There is not a lot of research on cyclosporine induced pancreatitis in cats, but it is well known in dogs and humans.

http://www.medscape.com/viewarticle/409496_3

Given that, I would be very cautious in adding cyclosporine to the mix right now unless everything else has been tried.

And do try to find out what kind of anaemia it is - treatment is dependent on knowing that.

 

my cat harry has IBD and is on budesonide. it barely raised his BGs (20 points).
any long term steroid can be hard on their system so it helps to have GI support like pepcid.

harry was mostly a FF eater and i sort of have to caution against it because of the MSG and other "natural flavors" they add but don't name. some IBD cats get the splats from that.

we switched to wellness grainfree augmented by chicken breast boiled in water (don't make the chicken more than 15% of the diet).

cleo got anemia from leukeran as well. we gave sucralfate for it. but remember, leukeran is a chemo and even harder on their system. if you can do it, i think budesonide is a better way to go. it's a stronger steroid than prednisolone BUT it targets the gut specifically and has less of an overall systemic effect so it doesn't raise BGs like pred will.

[edited to add: if you can possibly afford it, i'd listen to jess re the biopsies because of her cat's lymphoma experience. her experience was very hard earned.]

 

Thank you so much everyone for your feedback. I'm not sure what to do about biopsies and such. I live in the middle of nowhere, and though my vet is very good, he isn't an internist and there are none of them around here. There are apparently three ultrasound machines about 1.5 - 2 hours drive from here, but my vet said he didn't have much confidence in the people who do the tests. He's tried several times and they missed things (mostly vets who bought a machine and took a short course on how to use them). Tabriz did have one previously but they couldn't even image his pancreas.

I'm not sure why TAMU and Auburn are pushing chemo drugs, but it sounds like budesonide might be worth a try. Does it help at all with pancreatitis, or will it only take care of IBD symptoms? Is it dangerous for a CRF cat? Also, where do you get it? I think I read somewhere that you get it from Canada and that there are several types (one that has capsules like the old Contac I think I read was supposed to be better than others)?

 

FWIW, when Meowzi's GI panel tested positive for pancreatitis at TAMU (this was before Idexx offered the test), the TAMU endocrinologist spoke to her vettybean and suggested pred if she didn't improve. They knew she's a long-term diabetic, but didn't rule out steroids just because of the FD. And I would have tried it too. Pancreatitis is way more difficult and painful to manage with than FD, and I'd rather deal with the latter than the former. IMO.

 

HI Jess,

We didn't do a blood chemistry today, just a CBC. I also thought about that on the way home. Tabriz had a GI bleed previously from steroids and like you said, BUN went up dramatically because of his digesting the blood. Sucralfate took care of that fairly quickly, thankfully.

Like I said in another post, I'm not sure where I could get an endoscopy or laporoscopy done. I'd probably have to drive her to Auburn, which is about 2.5 hours drive one-way. My other problem is that I'm about to have surgery myself next week, and will be laid up most of next week. That will be followed by another very large surgery with a much longer recovery time. I'll also be non-weightbearing for 3 months, which will complicate matters in taking care of these guys to begin with. I'm guessing you are fearing lymphoma. I've worried about that too.

Shaikha developed soft stools which turned to diarrhea in April. By the time I realized that it was her and not Tabriz (she had always been very well), she was in bad shape. I don't know if it was undiagnosed pancreatitis that triggered the IBD, or IBD that existed and helped start the pancreatitis. One interesting thing is that in the months before she got sick, she was absolutely ravenous. We'd done blood tests but her glucose was normal then. I've read that IBD can make some cats hungry. She did have some bloating too, but I didn't realize it was that. That bloating probably existed for about 6 months prior to discovering this. She felt "different" than my other cats, but I thought it was just her. No diarrhea or inappetance during that time. I'm guessing, but perhaps she developed a sensitivity to the food she was eating and that led to the IBD? The reason I wonder that is that years ago I had a cat who was allergic to fish, and it was really difficult to keep his stomach happy because fish meal is in so many things. Though I tried to keep him on a fish-free diet, eventually he stopped eating and when we did exploratory surgery, he had tumors everywhere. It was so bad there was nothing to resect in his bowels, so we put him to sleep. At the time I was living overseas and it was long before things like chemo drugs were used, and where I was they wouldn't have been available anyway.

I will probably take her back in tomorrow to get a panel done. We did the CBC in my vet's office, and he has a machine that tests reticulocytes, but it isn't the sort of detailed count you'd get from a larger lab. I agree that we need to determine if the anemia is regenerative or not. I'll also talk to my vet about trying budesonide first for both cats. Do you know if it is bad for a cat with renal failure?

 

Hi Wendy

I forgot about this, sorry.

FWIW, it can be difficult to visualize the pancreas in some cats, even for experienced ultrasonographers.

I admit that I am not on the budesonide bandwagon. It does seem to have some systemic absorption (cats become diabetic on this drug, though probably a lesser % than with pred) and it does not seem to work well for pancreatitis. None of the internists I work with use it because they haven't been impressed with it. If you are really set against pred, you could try it--it does seem to work for some patients--, but keep a close eye on the BG.

That's another thing, it has to come from a compounding pharmacy. You can't do liquid, or flavored chewies, you have to get it in capsules with enteric-coated granules. There are big differences in price; I think Summit in Canada has a good price, that might be why you heard of getting it from Canada. But places in the US such as Veterinary Pharmacies of America in Texas will also compound it. Just make sure you are getting the coated granules and not a powder.

 

Actually, I'm not set against using prednisolone, especially since she did so well on it previously. If it makes her BG worse, I can deal with that. Even my vet was wondering whether we should just try it again despite the diabetes. It has also worked for Tabriz, but it does make his renal values worse. What we've done with him was to just use a very low dose and to try to get him off it as quickly as possible.

I've also heard the same things about budesonide. Some people have had great luck with it, while others are not convinced it works. TAMU was definitely of the later opinion, plus they had seen it make diabetes worse in several cats so they didn't think it was benign. I guess each cat is different. Some cats can tolerate epogen, but Tabriz couldn't. Some cats do great on leukeran, but Shaikha didn't (well, I do think it made her symptoms better except for causing anemia).

Jess, do you have any idea whether this anemia will resolve? Plumbs mentions that myelosuppression manifested by anemia can resolve in 7-14 days, but that severe bone marrow depression can result in pancytopenia that can take months to years for recovery. Tabriz has the latter, so I don't want Shaikha to suffer with that too. My vet has enough of a time finding donors for Tabriz every month.

 

The bone marrow depression from this drug is usually seen as a cumulative effect with longterm use. Honestly, I'm suspicious that there is a bleed somewhere This drug doesn't cause anemia that often, not so quickly and to this extent. To answer your question, I would expect a quicker bounce back (days/weeks rather than months) if the PCV dropped because of the chlorambucil; there hasn't been a lot of time for it to work on the bone marrow, so it stands to reason that the recovery would be quicker.

If your vet sent out the CBC, he can add on a reticulocyte count without having to draw another sample.

 

The only bleed I've dealt with was Tabriz's. If one exists, will sucralfate be enough to fix it?

My vet has a lasercyte machine. It does a retic count and % retics. I can't remember anymore what we did on Tabriz when he was diagnosed with anemia, but there was something we did to verify regenerative vs. non regenerative. There was so much going on at the time it is all a blur. I had fairly detailed records for him but lost most of them in a hard disk crash.

 

I got budesonide from my vet, I didn't need to go to a compounding pharmacy. If you and your vet decide to try it, I have some if you'd like it, I'll send it to you for free.

 

Now I'm curious--what does the rest of the CBC look like, specifically the RBC count and the hemoglobin?


BTW, I fed Boo the grilled Fancy Feast varieties, which probably wouldn't work for a kitty with IBD. We also used steroids regularly with him. His numbers were actually better on steroids than off.

 

See attached picture which shows her bloodwork before pancreatitis (2009), when she was first diagnosed with pancreatitis (5/17) and earlier this week.

 

Ok, I think her hct has dropped but I don't think that the 18.4 is the correct value. It doesn't match with the 8.5 gm Hgb. It should really be in the 24-25% range. The tech who ran this sample or the vet should have confirmed that with a spun hematocrit. (and 18.4 is a machine generated number, not a spun crit) Someone should have realized that the results just didn't look right.

My best guess is that the sample was lipemic or icteric, especially since this is a cat with pancreatitis. That is going to interfere with the readings on the machine. This is why i tend to be wary of samples run in the majority of vet clinics. It's easy to show someone how to run the instrument but you also need to be able to troubleshoot the results to make sure you're putting the right numbers out there.

I think this sample needs to be repeated by an actual laboratory with a note to correct for lipemia or icterus.


I just looked at those results and noticed there isn't an MCHC result for the last 2 samples. That pretty much says there's something interfering with the sample. That should have been a red flag right there.

 

My vet ran a PCV because he was suspicious about the results because several of them didn't look right to him. Her PCV was 20%. He didn't want to take more blood from her though because her values had dropped so much. BTW, in case anyone comments about the low WCB, that has always been the case with her. I only have records going back six years, but she always reads low. She was tested for FIV and FeLV when we moved back to the US, but all our cats were negative (we lived on an island where neither disease existed, nor did rabies). The rise in WCB was unusual for her, so he also checked urine to ensure her bladder infection was gone (it was), but he also said that other blood values were off so he wasn't sure of the numbers anyway.

He did run a mini-test yesterday to ensure that her BUN wasn't high. It was well within normal range. Her stool sample was also clear for blood, so he believes she doesn't have a bleed in her GI system and is attributing the drop in PCV to leukeran. Just to be safe though, we put her on sucralfate.

For my own knowledge, what is lipemia or icterus? Does this mean his machine is working wrong or is there a problem with her blood? Samples sent out to a lab cost over double what ones done in his clinic cost, so if we have to run these weekly through a lab it would be really expensive. On the other hand, if her having pancreatitis means that they can't run samples in the clinic, that would be good to know. No sense wasting money either. I'd just need to reduce how often I could run a CBC and perhaps just do PCVs instead in between lab CBCs.

 

Lipemia is when the liquid portion (serum) of the blood sample is cloudy and whitish due to fat in the blood. Some cats are more susceptible to this than others. Fasting before a blood draw minimizes this. Icterus is when the liquid portion is yellowish. It is usually due yo a liver problem. Both of these conditions can skew some of the blood chemistry results.

 

you CAN get budesonide in liquid form.
my vet orders it from a compounding pharmacy, golden gate pharmacy, and i get it in a 60-day supply in a 1mg/ml suspension flavored with bacon (other flavors available).
periodically we switch to prednisolone or augment with flagyl.

pred has more than doubled cleo's lantus dose and thrown her off tight regulation, tho in her case i can't risk discontinuing it because of her lymphoma. budesonide has barely raised harry's BGs (20 points).

 

I'm still on the fence about what to do. Her last leukeran dose was on Tuesday. I know we can't give that drug again though because of the drop in her PCV. I already have one cat who is transfusion dependent because of antibodies to epogen (and CRF, which was the source of his nonregenerative anemia), and can't risk another in that situation because my vet has enough trouble scraping together donor cats as it is that are a good match for Tabriz.

I've been told flatly that budesonide will have zero impact on Shaikha's pancreatitis. It may help IBD, but I think we've got that pretty well controlled with the change in diet to Hills d/d. She has nice normal stools now.

The big problem is that since we stopped the leukeran, her pancreatitis pain is back.:sad: On leukeran I was able to stop the buprenorphine. Today she was back to slinking around the house and hiding, which is classic behavior for her when she is hurting. Her abdomen also seems a little tender, so I am back to giving her buphrenorphine again. She's still eating, but needs a lot of coaxing (the timidity factor plays a role here; she gets frightened of her own shadow when she's hurting and any noise causes her to bolt while eating).

The other wrinkle is that she is finally OTJ. Her last dose of insulin was two days ago, so it appears that either the leukeran helped calm the pancreas or that she's recovered from taking steroids. I'm afraid to put any steroids into her as a result because I don't want the diabetes to return. She's had readings below 100 on the Relion meter and her numbers are also lower on the Alphatrac so I'm sure she's on a temporary or permanent honeymoon from diabetic symptoms, though I'll continue to test daily to be sure. She's also drinking far less water, another good sign.

Given what I've been told, my only options are prednisolone (since again pancreatitis is her biggest problem right now) or something else like cyclosporine. Given the reappearance of her pancreatitis pain, she obviously needs something to help because buprenorphine is only masking the symptoms.

I'm leaning against pred right now because she is insulin-free and I'd like her to stay that way. I'm facing several surgeries in the next few weeks and will need friends to help look after my two sick kitties. But if I give her pred, then diabetes will return, of that I'm certain and that's asking a lot of my friends because of the problems with monitoring. If I give her cyclosporine, that has its own consequences too because it is such a strong drug. My vet wants me to start her on cyclosporine and gave me some on Friday, but I've been delaying doing so because of the side effects. My first surgery is on Wednesday, but will be gone Tuesday and Wednesday and likely unable to care for them closely for a day or two more after that.

it's just a lot to consider right now and I'm not sure what to do.