Diabetic kitty w small cell lymphoma

Hello All

I posted a few months ago when my girl was diagnosed with pancreatitis and diabetes. We struggled for a few months getting her regulated but our vet finally sent us to Cornell to see an internist who specializes in GI abnormalities as she also had chronic diarrhea. After a lot of tests, we had an endoscopy and her the biopsy of her small intestine indicated small cell lymphoma.

The internist started her on budesonide and chlorambucil but she developed nausea, anorexia and vomiting so she’s currently just on the budesonide. The good news is the diarrhea has stopped and that’s allowed me to move her to low carb foods from her novel protein diet. The bad news is her pre shot numbers have been in the high 400s with 350 nadir. The vet just bumped her up to 3.5 units Lantus BID which has her back in the mid 350 range pre shot. He said he’d bump her up to 3.75 in a week or two but doesn’t like to jump too high too fast.

Has anyone here seen BG spike on budesonide? Or used it for small cell lymphoma? The plan was to give her a break from the chlorambucil but if she is doing so well on the one drug, I’d prefer to keep it simple and give her just that.

 

I had two diabetic cats on budesonide. for likely IBD. I only saw a very little rise in BG/increase in insulin. Did you also stop the chlorambucil? My Mario had SCIL and was on chlorambucil. He was aff the day after the chlorambucil. I found that giving famotidine with the pill helped. What really helped was going to pulse dosing (one large dose every 2 weeks) of chlorambucil vice a smaller dose three times a week.

 

I'm on my third cat now with small cell lymphoma, two on prednisolone, the diabetic (Neko) was on budesonide. Budesonide did not impact her blood sugars, though I have seen a couple cats here who were.

Were you on a chlorambucil protocol that was dosing every couple days, or once every two weeks. The latter one is much easier on them. As long as you do appropriate pre and post dosing with anti nausea meds like ondansetron and possibly Cerenia as well if she's vomiting, they should handle the chlorambucil just fine. I'm a little worried you stopped the chlorambucil cause otherwise the small cell lymphoma will not be controlled.

There are novel protein diets that are low carb, that are commercially available, but you don't need novel protein for SCL kitties.

We'd be better able to help you with dosing if your spreadsheet is up to date, at least the last couple weeks. And if you could add comments to the Remarks section about when you started/stopped meds, it would help us too. If you are testing now like you did what's in the spreadsheet, it's possible you are missing some low numbers mid cycle (AM and PM) and she's bouncing.

 

So, the plot thickens. Post endoscopy/biopsy Honey wound up in the ER vet with acute pancreatitis and UTI. They stabilized her and released her to me due to an impending storm in NY (we got 2 ft of snow). During her entire visit her blood sugar never dropped below 400 and was closer to 500 most of the time. She had just started Chlorambucil( 2mg every third day) a few days before the admission to the hospital. During her stay the ER vet reported a heart gallop during IV fluid administration and raspy breath. I got the report of the X-ray . Suspected asthma and suggested echo of heart to rule out underlying issues. In other words, she’s got a lot going on.
The Cornell vet wanted a reset. Treat the UTI for 14 days, stop chemo, get her eating but increase Lantus slowly up to 4 Units BID to get her BG down from the 500 range.

So many friends are suggesting it’s time to say goodbye to her but I’m working from home during the pandemic and she is hanging out with the other cats on the cat tree in my office watching the birds at the bird feeder and purring. I will admit it crossed my mind while she was on Leukeran...she was miserable but I’m willing to give her more time as long as I can keep her comfortable.

yes, I need to update the online spreadsheet. I track her numbers in an app and transfer before our vet visits.
Thank you all for the support

 

There's a better/newer chlorambucil dosing protocol that is once every two weeks, but a higher dose. Cats are a lot less nauseous on it. Neko did horribly on the every other method but had a lot of days in the every two week method where her appetite was normal and she felt good. My current SCL cat started on the every two week method, I would never agree to EOD again. My Neko also had kidney disease and heart disease (diagnosed at the time of her small cell). Chemo can lower their immune system, so the UTI is probably why that was stopped. Maybe see if you can get her restarted on the other "pulsed" 2 week chemo method when she starts back up. Remission rates are pretty good on that method.

Any chance you can get blood sugar tests at night, even before bed? Many cats go lower at night so you could be missing some night time lows.

 

Good to know there are other dosing intervals we can try on the Chlorambucil. The current plan is to finish up the Clavamox for the UTI and the buprenex for the pancreatitis pain then give her a week on Lantus and budesonide before starting the chemotherapy again with Cerenia added in. They are holding off the move to prednisolone until they evaluate her heart.

The internist at Cornell wants me to test her at home but manages the diabetes through fructosamine testing. To date she has had good control by that test but I’ve never been happy that her numbers are in the mid to high 300s. I usually run a home curve before each of her clinic visits. He’s seem more concerned about treating her underlying conditions and managing the diabetes around it.

I’m going to load the numbers in the spreadsheet this weekend and will get a few late night tests in. I get up at 5:00 (my body is still used to getting up to commute to work) so she gets tested, fed and injected before 6am. A nighttime nadir should be around midnight

 

I would agree with this approach.

Of greater concern would be a vet who was reluctant to prescribe treatment needed to help another condition solely because it might negatively impact BG levels. Sometimes an underlying condition needs to take precedence over the diabetes. If required, insulin dosing can be adjusted in response to any effect the treatment has on BG levels.


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I agree with the internist on the home testing. I found that the additions/changes in meds would sometimes play havoc with Neko's numbers for a while, until her body got used to them. It was a balancing act and home testing allowed me to keep that balance.

 

Hello. You are dealing with a lot! I would just like to ask/comment on the problems with chlorambucil. Were you giving your cat an every other day dose or were you using the pulsed dose protocol. Many cats will have too many side effects on the EOD dosing. It is not the current (up to date) method for administering the much-needed chlorambucil to a small cell kitty. Your cat would only receive chlorambucil every two weeks on pulsed dosing. In addition to that, with chlorambucil you must administer Cerenia and Ondansetron at the appropriate time to control nausea. There’s a specific protocol for how to dose it along with the chlorambucil.
The only reason I ask these questions is that there is no other proven way to control small cell lymphoma other than chlorambucil. Budesonide is not the drug of choice either, but prednisolone is, unless contraindicated by other concurrent medical conditions.

As you already know, steroids do increase Blood Glucose. I am sure that the moderators here will be able to take a look at your spreadsheet and advise you on dosing.

there is a very good group on groupsio for small cell lymphoma. Lots of good data there in their files section as well. A veterinarian who is a top specialist in the United States on small cell lymphoma also participates in the group as he is able.
Best wishes to you and your fur baby.

 

We are heading back to Cornell to meet with the internal medicine specialist on Monday. Soon after starting the chlorambucil/prednisolone protocol Honey developed a UTI that we have been unable to successfully eradicate. She’s been moved to Baytril for 14 days by her primary care vet but her blood glucose levels are still high. Primary vet thinks we may be looking at a kidney infection so I will curious to see what the specialist thinks. His staff is super responsive but getting an appointment takes about four weeks. I’m concerned about the high flat numbers since the beginning of February but she has so many things going on, it’s hard to know what’s keeping her numbers so high.

For those of you who had cats on prednisolone, did you see a dramatic increase in blood sugar or a tiny bit?

 

Tagging @Wendy&Neko to ask her to help you with the above question.


Mogs
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With the testing you have in your spreadsheet, I see one of two possible scenarios going on. Option 1 - the pred means she needs more insulin, I've seen as much 2-3 extra units needed, sometimes less. An infection would make it worse. Option 1 would mean the dose is too low. However, no way am I suggesting that you increase the insulin, there just isn't enough mid test cycle to say this is what happening. Option 2 - The drugs are helping her, she's going lower mid cycle when you aren't testing, and bouncing the rest of the time. Option 2 could mean the dose is too high. I can think of another option, but I presumed after the cardio workup you were cleared to start the prednisolone.

To answer the question specifically, with many things cat, ECID (each cat is different). My non diabetic cat with SCL went up about 30-40 points on 10 mg of pred, less so on 5 mg of pred per day. Of cats here on insulin, it's ranged quite a bit. Sometimes pred is reducing inflammation, which can increase the blood sugar, so impacts of pred are not as bad.

Some feedback on the plan to reintroduce chlormabucil (which is a good idea if the pulsed or every two week plan), please see if you can get the vet to prescribe ondansetron. If is much better at reducing nausea from chemo. It's a human drug you get at the pharmacy, you just need a prescription.

 

@Wendy&Neko - Thanks, Wendy.


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Thanks @Wendy&Neko , we went to Cornell yesterday and the internist said many of the things you did! You were right on the money

The internist actually quite pleased that she is gaining weight even though she’s a big girl. He took the weight gain as a sign that her insulin isn’t too far off since most diabetic cats struggle with maintaining weight. He felt the same on the lymphoma front. She had previously lost 4 pounds since September despite eating everything in sight. Of course, we’re waiting for the half dozen tests he ran to come back before making any changes but he feels we if can tweak the prednisolone and eradicate the UTI/kidney infection, the insulin dosage will not substantially change. Although he said it will always be a balancing act since she has quite a few medical issues. His philosophy is to fix the underlying issues and see how the blood sugar levels shake out instead of boosting the insulin and risking a hypo incident when the infection is gone and steroids are decreased. He’s on the fence with the Leukeran, and may hold off until she is long past the infection before restarting. He asked me to stay patient and stay the course.

 

Thanks for tagging Wendy&Neko!

 

Hi @Suzanne & Darcy,

Not OP so I hope you and OP don't mind, but I came across this and was wondering if you could share the link for the groupsio for small cell lymphoma? or let me know how could get there as my kitty Cooky has been diagnosed with it and started the chlorambucil every two weeks with daily prednisolone. It's been one week so far. He's taking cerenia as well, but I have not heard of ondansetron that you mentioned. Are cerenia and ondansetron typically taken every day, or only at a specific time during the 2 week cycle when nausea may be at peak?

 

Hi there. The Cerenia is given daily, usually 1/2 to one hour prior to administering the Chrlorambucil. The Ondansetron (Zofran) is given about 1/2 hour prior to administering the Chlorambucil and every 4-6 hours afterwards for a few days after you give the Chlorambucil, to make sure to keep any nausea under control. It sounds like your vet knows what he/she is doing ... using the pulsed dosing and the daily prednisolone. Did Cooky have a biopsy or how was the SCL diagnosed?

 

Hi again. Below is the link to the io groups site. Go under search for groups. The name of the group is Feline_Smallcell_Lymphoma. You can apply to be added as a member of the group. It's a good group with very knowledgeable group owner. She's a big stickler for people getting their cats biopsied so that is why I asked about it.
https://groups.io/

 

@Suzanne & Darcy
Thanks! We attempted 2 aspirates that weren't conclusive and ended up doing a surgical biopsy to confirm. Our oncologist gave us the choice for the chlorambucil to do it everyday. every other day or once every 2 weeks, and we picked once every 2 weeks purely because it would be less miserable for us and Cooky (it's quite a battle to give him meds and everybody feels bad). But I was wondering if maybe the every day or every other day would have been better for a more consistent dose so I'm relieved to hear that the once every 2 weeks is better! And we're doing the prednisolone as transdermal thru the ear. Thanks for the pointers regarding timing for cerenia and ondansetro, I didn't think of it and it makes sense.

Oh and thanks for sending the groups.io group, I'll dive right in

 

Great. The every other week dosing is the most up to date method. It gives the best results with the best chance of remission and the overall less amount of chemo over time so it has the least amount of side effects. Good luck with Cooky. I had a cat on chlorambucil and he did very well for a number of years.

 

I had a kitty with small cell lymphoma who became diabetic from the prednisolone after being on it with the chemo for 2 months. His Oncologist weaned him off of the pred so he was only on the chemo(Chlorambucil) for the last 9 months of treatment. She said the steroid was more important at the beginning of treatment, and he did well for the remaining 9 months of treatment without it. He lived another 4 years once treatment was finished until he was almost 18.