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Lymphoma/liver Failure

by rbvmd - February 11, 2010

Daisy is a 6 year old F/S Collie. She was adopted from a rescue in 10/08. When adopted she appeared very "sway backed" and had weakness in her paraspinal muscles, djd in her hips and spondylosis in her lumbar spine. In early 2009 she developed what appeared to be immune mediated disease signs with lots of damp heat (gingivitis, vulvar ulcerations) which seemed to respond to homeopathic care (done by another vet). In 6/09 her gingivitis got much worse, she developed peripheral lymphadenopathy and hypercalcemia and she was diagnosed with lymphoma. Since then she has been seeing an oncologist for chemo as well as myself for acupuncture and another vet for Chiro. Daisy has the MDR gene mutation and has not been able to tolerate a standard chemo protocol. For the last several months she has been getting CCNU every few weeks and a tapering dose of prednisone. Her blood work indicates her liver values are climbing rapidly and now she has an alk phos >8000, ALT >800 GGT >60, and very elevated bile acids as well as severe lymphopenia (rest of CBC OK). Bile acids and lymphocytes had been normal up until now. Daisy's current meds in addition to CCNU and pred include:
Famotidine, glycoflex, fish oil, probiotic, Oncosupport from RX vitamins for pets, both SAM-E and milk thistle 200 mg each BID, Maitake D fraction and Max's Formula from Jing-Tang harbal.
Her shen is excellent, her tongue is pale in the center and a little red around the edges, sl dry and flabby. Pulses are deep and a little weak, and she has lots of trigger points along her back.
The good news is that despite her catastrophic liver values, Daisy feels great! Appetite and stool are normal (diet is mostly high protein, very low carb homemade food).
Does anyone have any suggestions for helping strenthen this dogs liver? I don't know if it is being destroyed primarily by chemo drugs, infiltration of lymphoma, or both. I don't want to add more stuff to her extensive pharmacopia unless I have a really good rationale for why it might help. Does anyone think Hoxsey formula migh help at this stage? I have never used it and don't know much about it.
Wonderful dog, wonderful owners, any help appreciated!!!!
Rachel Bergman

by naturevet

February 10, 2010

Hi Rachel,

I think it's safe to say the dog is under severe oxidative stress, even before chemo. It likely underpinned the inflammation and was the source of the mutation that created the lymphoma. Chemo has just added to that load.

A decent antioxidant, anti-inflammatory, anti-neoplastic formula is what you need now, but that is also easily tolerated. I'd look at Si Miao San, perhaps with added Dang Gui (20g per 100g) to start with. It's been helpful in peripheral lymphadenopathy and has augmented chemo effectiveness.

An antioxidant diet (home-cooked or raw) is also a consideration here.

I'd start with just that one formula. Hoxsey is probably too strong at present given the weak pulses. You'll need to take it week by week, possibly adding in other formulas as the case shifts and (hopefully) improves.

Steve

by bannink

February 12, 2010

I wonder why they are not taking her off CCNU and pred with liver values that high? Is she not in remission? 9 months is a long time to be on CCNU and it will be hard to support the liver if she is experiencing CCNU-induced liver toxicity and still receiving CCNU. Dogs have died from liver failure induced by CCNU. L-Spar is safe in dogs with MDR gene mutation, as is Cytoxan.

In any case, I would recommend getting her onto higher doses of Milk Thistle and Sam-E with a reliable potency. I use Marin and Denosyl for these guys and have been happy with the responses. And there has been an as yet unpublished study (out of UC Davis if memory serves) that Denosyl and Marin combination does seem to be protective against CCNU liver toxicity in a preventative setting so I would switch to those at least.

Erin

by rbvmd

February 12, 2010

Thank you for your quick response! Daisy saw the oncologist yesterday, who decided to continue with CCNU and pred with the rationale that the lymphoma will kill her in a few weeks without chemo, and the chemo might take sl longer to kill her. Daisy has never gone into complete remission with any chemo combo. I know she had L-spar earlier on, and am not sure about cytoxan. I'll double check what form of SAM-E and milk thistle she is taking. Since she sees multiple vets, I have not been providing those. How high a BID dose would you give this 50-55# Collie?
Thanks for the Si Maio San suggestion. Can you recommend a good reference to help me learn more about when it would be appropriate to use hoxsey formula? If I had started it earlier with Daisy might it have helped?
Rachel

by naturevet

February 12, 2010

Hi Rachel,

That's a hard question to answer. Hoxsey is a good choice when the circulation is very peripheral, the pulse strong and easily found, and the heat signs very prominent. That will help you watch for good cases in the future.

I'd dose heavily with Milk thistle and SAM-E if you're going to use them. I haven't been hugely impressed with SAM-E myself, but I also know Erin well enough to know that if she recommends it, it's sound.

Good luck with the case. You've got some options yet. My advice would be if the dog starts to rally a bit, we look at reducing the chemo dose and adding in some other formulas instead.

Good luck!

Steve

by bannink

February 16, 2010

Hi Rachel,

Sorry for the delayed response. I never use over the counter Sam-E because I don't feel it does anything. The potency is too questionable. Denosyl is my choice and I usually use it at the recommended dosing (for this dog probably 425mg) once daily. Be sure they are giving it on an empty stomach, or at least 1 hour before feeding, as food inhibits absorption and therefore efficacy. For milk thistle I have done this two ways - if over the counter I use a really high dose - for this dog something like 500mg twice daily. I have gotten more into using Marin lately because of difficulty in finding concentrated formulations for large dogs and have been happy with it. It seems to be easier for people since the concentration of over the counter milk thistle is usually quite low (between 80-200mg). Again, for the Marin I just use the recommended dosage and round up to the next highest dosing scheme if they are at the higher end of the weight on dosing guidelines.

Erin

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