Leo (Leoberry) - the high doser

[Wendy&Neko]

On the Feline Diabetes Message Board, most of the acrokitties are over on the Lantus/Levemir forum. Many of us have chosen not to go over to Facebook because it is a closed forum there.

Jeff, I love how Leo's dose is coming down. And such an adorable picture of Theresa with the furbabies! It took a little while for Neko's constant hunger to die down after her SRT. As Leo's numbers get more even and lower, you'll find the hunger improves. Good luck with the mast cell removals.

 

[JeffJ]

Thanks Wendy. Leo is digging at the bump/growth on his head. So it will come off in the next 2 weeks. The new picture shows him hanging with his bud Little Dude - they are good friends.

This week Leo is doing good. Pretty stable. I just updated his numbers. His P.M. numbers went up this week. He has never had good (5-9) hour nadirs. The second tab shows his graphs - a definite trend down for insulin, very noticeable in December 2016.

His hunger has subsided a little this week. And we gave him like 6 tiny pieces of Little Dude's food. Not again! You can smell the results a block away when he poops! OMG - they could use that for crowd control

Tonight, everyone got cooked fish. Two days ago, everyone got cooked chicken. What a life.

For Facebook. I never joined. I learned about diabetes and Acro here, and have received gobs of help. I'm probably like a lot of other diabetic or Acro owners - we just wish we had normal kitties. I help a little bit with some of the newbies' questions here.

 

[JeffJ]

Week 20 after SRT treatment
Leo is still getting lots of lovin', and his Acromegaly symptoms are receding.
Now = ~15 units/day of insulin (Levimir)
Pre-SRT = 36 units/day pre-SRT.

Some nice side effects of recovery:
1) Neuropathy
Prior to SRT, his neuropathy symptoms were real bad, he was walking on his hind hocks a lot. He had trouble climbing.
Now he often runs to get food. And he is no longer walking on his hind hocks. He has drastically improved but is not fully recovered. We are really happy this recovery happened.

2) Food anxiety
Prior to SRT he was "dying" for food all the time, even with proper insulin doses.
Now he is hungry a lot. But he doesn't live in the kitchen all the time. He seems to get enough calories. As a result he comes to visit with us in other parts of the house. Leo seems more contented now that he hangs out with us more in the rest of the house.

Insulin usage:
His recent insulin usage is listed below. The reduced insulin also means the pituitary tumor is putting out less growth hormone (Insulin-like Growth Hormone (IGH-1))...making for a healthier Leo.
Insulin usage summaries:
~15.0 units/day in 3rd week of Jan 2017
20.3 units/day from 10/23/2016 - 1/5/2017 (last 2 months)
22.6 units/day from 8/25/2016 - 1/5/2017 (last 4 months)
36.0 units/day in Sept 2016 before SRT therapy

In the picture, Leo looks small. It's perspective. He is actually bigger than (orange) Little Dude. Theresa loves it when they hang with her at night. Who wouldn't ???

 

[Wendy&Neko]

Awesome update on Leo. It's so nice when there becomes life outside of food!

 

[JeffJ]

Mast cell growths - surgery today
Poor sweet Leo said "Halp - I don't want surgery!" as I drove him to the vet. In reality, he didn't make any noise going or returning from the vet. He stayed there overnight last night. Then had surgery early this morning. The vet removed 5 mast cell skin growths. Well, one of them was just a cyst. Part of his head is shaved and part of his front legs are shaved. We paid to have the largest growth sent for histology.

They didn't give insulin this morning. I picked him up in the afternoon.
BG = 550+ Whoa!
So he got 9.0 units. Poor kitteh. At least we know the levemir is effective since he never gets that high with current daily doses. He will get pain medication for the next 2 days to help recovery.

He also stored up a present for his arrival at home. Phewie. That sweet kitteh could probably clear out a bar room! How can such sweet cats drop such vile deposits in the litter box!?

 

[Wendy&Neko]

I hope the biopsy comes back as boring. Poor little Leo. I'm glad he's home now.

How can such sweet cats drop such vile deposits in the litter box!?

One of the things I love about a raw food diet - very little smell!

 

[Sharon14]

Poor Leo, he's been through a lot. You and Theresa are doing a great job!

 

[JeffJ]

Thanks. Leo is such a sweet fur kid. He is so happy to be back home - purring up a storm when we have been rubbing on him.

Another high BG reading this morning:
AMPS = 395
We are ensuring he gets plenty of food. He didn't eat much yesterday. But his figure is hardly svelte, so if we're lucky he lost an ounce or two over the last 2 days :-0

 

[JeffJ]

I took a couple of nadir measurements in the past few days. Leo doesn't nadir very much on Levemir. He is doing well.

He is now several days post-surgery for the mast cell growths. All he seems to do is purr when I rub him. Plus he hangs with Little Dude and is sweet all the time. Who could ask for more?

 

[Sharon14]

Jeff how is Leo doing?

 

[JeffJ]

Hi Sharon (and all), thanks for asking. I was off the forum for a few days, mostly working.

Post SRT +25 weeks
Leo and Little Dude are almost inseparable now. They hang out all the time. We are happy that Leo has regained a kitteh brother. There is a lot of purring going on, lots of co-grooming, and sometimes a little wrestling, and they usually sleep together. They often go into the fenced backyard together and hang out - looking for bugs and mice. It is great, just plain great.

SRT +6 months (almost):
- ambulatory with almost no neuropathy
- still hungry a lot, and still overweight- and he often trots or runs to get food
- stable at 4.5-5.5 Units/dose, less than 1/3 of his pre-SRT doses (18.0 units/dose)
- regular with urine and poop, so no issues there
- skin is recovered from non-cancerous growth removals
- very soft and love-able

His chart is updated, including the graphs on tab 2. He was recently at 7.0-8.0 Units, so he is still coming down in dosage. His body still resists nadirs. If we give him a little more insulin, he tends to nadir at the 12 hour mark. That makes it hard for us to dose him. I'm keeping him safe, and not dosing under BG=200. I suspect Leo may have some pancreatic diabetes. He has never had a true hypo event, although he did get to BG=60 once last year.

Fur regrowth (from Feb 8 to March 4):
His fur is slow to regrow back over the mast cell growth removals. So he still has several velvety soft patches (2 on legs, one on head). We rub them to make the fur grow back. The lab results were negative for malignancy - YAY!

Neuropathy recovery
He had real bad neuropathy pre-SRT. To the extent that the "big decision" was in play. His neuropathy is almost gone. We sometimes feed on the washing machine.There is:
- 1.5 foot high wood step,
- then another 1.5 feet to the washing machine.
He now has very little trouble getting up there. This week, he voluntarily jumped from a coffee table to the top of the couch (2.0 to 2.5 feet). Not amazing for a 6 month old kitty, but pretty good recovery for Leo. He often gets on a chair and begs at the kitchen table - and 3 months ago, he couldn't do that. If any one is reading this, and your cat has neuropathy, there is hope. Your cat can recover almost completely with proper BG regulation and some B12.

The same 1.5 foot high step/block by the washing machine - blocks the droolers (aka doglets) from poop wrangling. So Leo has to jump over each time to use the litter box. It's good exercise for his hind legs.

We love our fur kids and Leo is still making good progress. We hope he is outside the bell curve of "expected 600 days of extra life after SRT". He is almost 11 years old and I hope he is with us for many more years. A dose of cuteness (picture) is attached.

 

[Sharon14]

Sounds like good news all around! So happy that Leo is doing well and that he and Little Dude have become so close.

 

[Wendy&Neko]

We hope he is outside the bell curve of "expected 600 days of extra life after SRT". He is almost 11 years old and I hope he is with us for many more years.

Neko had almost 4.5 years after her SRT. The 600 days is an average, but remember that many acro kitties are seniors and often it's other things that take them. I hope the same for Leo.

There is nothing wrong with a nadir at +12 or preshot time. Neko often did it on Levemir. Consistent dosing will really help their blood sugars. With acrokitties, you do want to try to keep their blood sugar under renal threshold as much as safely possible. Even after SRT, kidney disease is common for acros so you want to try to prevent them from having to do extra work.

Love the pic of Leo and Little Dude. And I am so happy the biopsy came back negative.

 

[JeffJ]

Thanks Wendy and Sharon.

Leo is not as active as his younger days. But he still likes to play with toys (mouse on a string, etc). We try to keep him active, and I think the exercise is good. I'll work on getting his BG down a bit more. It can be challenging with our work schedules. Our target is consistent dosing like you said.

We were not sure Leo would bond with Little Dude. Just in the past month, they started sitting and sleeping next to each other. Now we have hundreds of pictures of them already. No pictures from tonight though - Little Dude caught a mouse and ate it on the back porch. Leo watched intently. Our sweet boys.

 

[JeffJ]

Leo was doing pretty fine until a month ago. In general, his insulin demand went down to 5.0-6.0, achieving 150-300 BG ranges. And he always had a healthy appetite.

His recent weight was 17 pounds. But in the past 4 weeks he reduced his eating, and he is now 16.5 pounds. And now, he stopped eating for 3 days because the food always came back up. We have been to the vet multiple times. He is on anti-nausea and hunger-stim pills starting today (cerenia and cypro). I've read all the "not eating" threads and always hoped it wouldn't happen to Leo. I'm giving him minimal insulin to keep BG down, targeting 150-250, but avoiding any potential hypos.

Diagnosis included blood work and ultrasound:
- thickened abdominal walls (intestine)
- high white blood cell count
- normal kidneys
- enlarged adrenal
- small nodule on spleen, which the vet said, can be a regenerative nodule, but could also be a tumor
- no blockage in intestines
- no pain upon probing areas of his soft body

I just syringe-fed him. If the food stays in him, he will get more. If he stays in this poor shape, he will get exploratory surgery next week. I'm not sure that would be fruitful unless a tumor is removed. If they find his intestines are shot, there is no real solution there.

Acromegaly causes different issues. It is possible one or more of the abdominal issues has caught up with him. Our vet is a very good cat-only, 40 year old vet with great experience. She is helping us with good advice and answers all our questions. She is having a training day on Monday, but said that if Leo is still pretty bad, she will treat just Leo that day. That's the kind of vet we have - great. We are hopeful for the best.

 

[Olive & Paula]

Have you tried smaller meals given more often?

 

[Wendy&Neko]

It's not uncommon for acrocats to have thickened bowels. Actually, since Neko was diagnosed with thickened bowels I started seeing a lot more cats everywhere with it. It could be IBD, or small cell lymphoma that causes the thickness. Maybe even the acromegaly. To determine which it is, the vet will need to take a sample of the bowels, either with surgical biopsy or endoscopy if the thickness is in a location the scope can reach. Possibly as part of the exploratory surgery. Both IBD and SCL are treatable. My civie had IBD that morphed in SCL. He ended up with one prednisolone a day and every two weeks a chemo (pills). SCL kitties can live 3-4 years past diagnosis, so it's definitely worth treating. My guy ended up with pancreatic cancer after 1.5 years, it wasn't the SCL that did him in. Neko couldn't have a biopsy due to her heart condition, so they just treated for SCL. In her case she got budesonide instead of pred, again due to her heart. Budesonide also has less impact on the BG's. She also took the chemo (Leukeran or chlorambucil) every two weeks.

You might want to see if your vet will give you a prescription for ondansetron (Zofran). You get it from human pharmacies. It's an alternate for nausea that sometimes works better than Cerenia. The two drugs target different nausea receptors. I find it good to have both on hand, especially before the weekend.

Did the vet also run a SpecfPL blood test? Thats to check for pancreatitis - another common condition with our diabetics and with kitties with GI issues. If positive for pancreatitis, it can be very painful, so you'd want to add pain meds (buprenorphine) and possibly fluids to the mix.

Sending many healing vines for Leo. I hope things turn around soon. I often had to syringe feed Neko and most time just getting a little food in her kick started her appetite.

 

[Sharon14]

Oh Jeff, I'm so sorry Leo isn't feeling well. Sending prayers and healing vines

 

[JeffJ]

Thanks Sharon. And thanks Wendy for the detailed backgrounds. Much appreciated and I will discuss with the vet next week. The cerenia and cypro started today. I also hope this syringe feeding jump starts his appetite. The vet did say something about small cell sarcoma being treatable.

Well...Leo got syringe fed 3 times (4pm, 7pm, 10pm) and so far that food is still in him. Also
BG= 400
Dosed 4.0 units 9pm

Those syringe feeding videos should start by saying "First go buy a bunch of towels, and a case of paper towels."

 

[Wendy&Neko]

Those syringe feeding videos should start by saying "First go buy a bunch of towels, and a case of paper towels."

Good one Jeff. I remember the first few times was equal parts food in the cat and on me. Getting a good feeding syringe also made a big difference. I am glad the food is staying in.

You might want to keep a log book of what proteins you are feeding and what the output looks like or if there is vomiting. IBD is one possible diagnosis, and it can be a food allergy that makes it worse.

 

[JeffJ]

and thanks Woodsywife. Yes, Leo gets a bunch of small meals every day...usually.

I'll keep a log of the health activities. I might even get off my butt and start typing it in again. It was pretty boring for awhile....5.0-6.0 almost every dose. I hope it gets boring again.

 

[JeffJ]

Leo is not accepting the syringe feeding well. Over 3 sessions, probably 3 table spoons. And we are dosing him water with a syringe too. He seems to have trouble swallowing. He will probably go to emergency vet tomorrow so they can hydrate him. Then to the vet on Monday for exploratory surgery. He is not doing well at all, and is as listless as I have ever seen. We are pretty worried at this point about the outcome.

Even if they find an issue, but he won't eat or drink - or accept syringe feeding, then we can't inject food and water into his stomach on a daily basis.

He does seem to have trouble swallowing. And he had issues with that over the past month or so.

 

[Wendy&Neko]

The vet can always put in a feeding tube to help with nutrition and even medicating. I haven't had to deal with one yet, though have come close. Luckily my crew were good with assist feeding. From what I have hear from others the feeding tubes have been life savers.

Thinking of you and Leo.

 

[JeffJ]

Thanks Wendy. We'll ask them to tube feed him tomorrow then.

For syringe feeding - he is spitting the food out. And for water syringe, he had trouble swallowing.

 

[Sharon14]

Here's some info on feeding tubes
http://catinfo.org/?s=feeding+tube
Hope Leo starts feeling better soon!

 

[JeffJ]

Thanks Sharon. That doesn't look like fun, but we may be at last resort on this.

 

[JeffJ]

Yay. Team effort with Theresa - we got 1/4 cup of liquidy food into Leo (science diet AD). Almost all of it got into Leo. Then he ate 4 Dental Diet crunchies by himself as a followup.

There is a real art to syringe feeding - maybe just persistence and rolls of paper towels. Still not out of the woods - we'll definitely have a vet visit on Mon if emergency, or Tue for deeper diagnostics. Will update thread with significant stuff.

Whew.

 

[Sharon14]

Great news! Keep it up Leo!!!

 

[JeffJ]

Summary of last few days, and cruddy day today.

- Limited success with syringe feeding
- Variable BG, resulting in some no-dose periods
- Not drinking enough water, and urine very dark yellow as a result

Then a darned HYPO. I never, ever get him that low. He is always 100-300, like clockwork the last 4 months.

Yesterday, 3 syringe feeding sessions, about 3/4 cup of food total. Last feeding was 9pm last night.
BG - 450, which is super high for Leo. His range in the last 2 months is 150-300
No Dose yesterday a.m,.
So lastnight 9pm dose was 4 units, where a normal dose is 6.

Tested him at 7am...earlier than normal
BG = 40
Emergency Karo syrup, and rush to Emergency clinic.
Immediate glucose injection given. He is on a glucose drip all day today.
BG = 140 now

Our objective is to get him stable enough for emergency exploratory surgery to find the underlying cause of his non-eating. And we'll have them put in an esophagus feeding tube. The vet called it an e-tube. Cautiously optimistic we can pull thru the next 2 days. Our boy...we love him so much. He can't go now.

 

[saltycat]

Keeping Leo in my thoughts. He is a tough guy to be going through all this. I don't know if it was mentioned above, but if he is put on a feeding tube I seem to recall with Acro cats it is advised to use a size smaller tube due to the tissue buildup.

Prayers for your little guy

 

[Sharon14]

Jeff, sending prayers and healing vines for sweet Leo

 

[JeffJ]

Spreadsheet updated thru today. Hypo was 10 hours after PM dose. Leo hardly ever hits a real nadir.

Thanks all. We will know more in the morning, whether he is healthy enough for exploratory surgery. If we can just get him eating again, we can work through other issues. He has not vomited any of the syringe-fed food in the last 3 days, so the anti-nausea was working. I hope I didn't damage his body with that damned hypo.

Picture: Leo (black tabby) with Little Dude (orange) on 6/11/2017 just a few days ago.

 

[Sharon14]

Colin has had a few out of nowhere hypos and seems none the worse for them. Maybe try to start doing a few before bed tests at night to see where he's heading. Sending tons of prayers for Leo, you and Theresa

 

[JeffJ]

Thanks Sharon, I agree. Leo is stable, and does not seem affected by the Hypo. Chart comments are updated.

Leo was eating some "kitty McDonald's" at the hospital -> Friskies. At least he was eating. There was also Classic Pate there - in case he wants "normal".

Current plan is to take him off glucose drip tomorrow 7am and take him to regular vet for further evaluation. We need to diagnose the underlying issue of not eating.

 

[Sharon14]

Glad he was eating some. Colin loves Friskies but it spikes his glucose, so I give him some when he has lower numbers. I hope you can find the cause and fix it and hopefully without surgery. Keep us posted.

 

[JeffJ]

Leo still not eating. Without a root cause, that is a death sentence since we can't force him to eat all his life. Bullets:

Discussed options 45 minutes with primary vet
Selected exploratory surgery, which was done today.

Findings
Intestines have no sign of blockage from stomach to colon, looks normal.
No blockage at all. No hairballs, no grass, nothing.
Overall - looked like normal abdomen
Discoloration of liver, which is fatty liver.
Various biopsies taken.
intestinal walls thickened - biopsied
lymph node was enlarged - biopsied, potential issue
samples take 7 - 14 days to evaluate

If ulcerative colitis or lymphoma -> causes no eating
Ulcerative colitis -> same

Could be worse. Last year Scoobs had similar procedure on July 1. His intestines were shot, and we made the "hard decision" since there were no options. My sweet boy Scoobs, I miss him so much.

For Leo:

Vet believes the issue is either
IBD or lymphoma

Esophageal feeding tube was inserted at neck area.
We will force feed him for a least a month.
has esophagus tube in
feed in 12-24 hours

Surgery recovery -
2 weeks for scars to heal up

Followups:
- act upon biopsy results
- tonight on glucose drip at animal hospital
- tomorrow am, JJ and Theresa learn how to feed Leo thru tube

Our sweet boy Leo is a trooper. We'll get through this.

 

[Sharon14]

Sending healing vines for sweet Leo

What have you been feeding him? I know several people here with kitties that have belly troubles try to feed foods with out carrageenan, and limited, novel protein ingredients.

 

[JeffJ]

Thanks Sharon. The house kittehs all get Fancy Feast Classic - maybe 10 different types. Also once a week cooked chicken. He was fine with all of that for a year. Then one month ago, he would eat a little, then run from the food - of all types. Then 1 week ago, barfing the food up.

I suspect something in his gut is wrong. He won't eat anything for the past week or so. We disliked cutting him open, but this will allow us to know pathology of his intestines.

 

[Sharon14]

How's Leo?

 

[JeffJ]

6/20/2017 (Tuesday)
- Leo's exploratory surgery occurred
- tissue samples sent out, results in 7-10 days
- esophagus feeding tube surgically setup
- overnight stay at hospital with glucose and 24/7 monitoring

6/21/2017 (Wednesday)
- Leo transferred to vet for the day, did well, stayed on glucose until 4pm
- Leo came home for remaining recovery
- Alert but subdued, did not fight during e-tube feeding, happy to be home
- on Bupe for pain
- chart updated, doses will be 1.0-1.5 for time being to ensure no hypo

 

[JeffJ]

Now that he is "feeding", his immediate downhill issues are resolved. (No eating is the end).

He was pretty bad before the hypo. All the fluids, glucose, and food have pretty much brought him back to the good state he was in - one month ago. I sure hope the test results uncover some issue that we can treat directly. Attached pic of Leo recovering at home tonight. Our sweet kid is home!

 

[Sharon14]

Glad he's home! Hope you get the results back soon and it's easily treated. Keep us posted.

 

[Phoebes (GA)]

Prayers for Leoberry!! Head bumps and hugs for daddy bean.

 

[JeffJ]

Thanks all.
He is doing much better now that he is getting food. Today, he of course ate some crunchies and Fancy Feast...which he wouldn't touch pre-tube. He doesn't like the e-tube, but he is not trying to remove it.

He is still subdued, probably from the morphine. He does not seem to be in pain at all....probably because he is higher than a kite. Very responsive to being brushed 10 times a day

Pee - normal
Poop - pretty runny, but at least it happened
Chart updated.

 

[Wendy&Neko]

I am glad Leo is back home again.

Vet believes the issue is either IBD or lymphoma

The results of the biopsy of the bowel walls will tell you which you are dealing with. Did the vet talk about treatment plans? At some point, if you aren't already, you might consider talking to an internal medicine vet. The IBD/lymphoma in addition to acromegaly/diabetes may not be something your vet is familar with. My vet directed me to an IM vet at that point.

 

[JeffJ]

Hi all.

We just got confirmation that Leo has small cell lymphoma (SCL). It is spread thru his intestines, lymph gland, and 2 other organs. The vet estimates he has had SCL for 3-6 months. Maybe as a side effect of Acro, or even the Acro SRT.

All cats and humans die. Our objective is to treat Leo until his quality of life is reduced. He is doing pretty good now. Just last night he ate 3/4 bowl of food. And he was playing with me and Little Dude with a stick/string toy. For the time being, we will continue to use the esophageal feeding tube. His eyes are alert, and he has perked up from the additional feedings.

Our vet has direct experience with SCL. She even had a personal cat with diabetes and lymphoma, which lasted another 4 years after initial treatment. We don't expect that timeframe with Leo. Another 6-24 months would be amazing. We are going to treat Leo with Chlorambucil (chemo) and Prednisolone and love. We will start with the additional chemicals this week (I hope). The vet said she would refer us to an IM vet, but I just don't think we need that for sufficient treatment.

 

[Wendy&Neko]

I am so sorry about the diagnosis. There is an online feline small cell lymphoma group you may wish to join. They are very knowledgeable and an intermal medicine vet well versed in SCL watches and sometimes comments. It's great your vet has personal experience. I am glad Leo is feeling better and feeling like playing a bit. That's a great sign.

Neko took budesonide instead of prednisolone for her SCL, due both to her diabetes and her heart condition. Prednisolone can impact the blood sugar. But that's OK, it may just mean you have to increase Leo's insulin dose a bit to compensate. As you will see in the small cell group, there is a newer protocol for giving chlorambucil (Leukeran is the brand name), and it is given every two weeks in a slightly larger dose. The chances for remission are as good as the older protocol of giving it every other day. The advantage is giving the meds less often. Chlorambucil can cause nausea for 1-4 days after it is given. Neko was originally on the EOD (every other day) protocol and never got away from nausea. The every two weeks protocol meant that after 4 days of nausea, she felt good for 10 days until the next dose. You will want to get some ondansetron (Zofran) from the vet. Cerenia can also work, though I've seen ondansetron do a better job. With Neko, I found she needed both ondansetron and Cerenia towards the end. The civie with SCL hardly got any nausea. I gave him some ondansetron before the dose to block the nausea receptors, and one the day after, and he was fine.

Wishing you all the best. Neko only lasted 6 months after her SCL diagnosis, but she also had kidney and heart conditions. The civie lasted 1.5 years after his diagnosis, but was taken by something completely different. He went into remission after starting treatment for his SCL and had great QOL. Hoping for the same for Leo.

 

[JeffJ]

Thanks for the detailed information Wendy. It is hard news for us. But in a way, I'm glad the vet found something, which is somewhat treatable.

I just joined that SCL group, thanks. We will pass that dosing info to the vet. Leo and Theresa are going to the vet tomorrow for a checkup on the tube and current condition.

The ongoing pre-drug nausea from the SCL must be causing the non-eating issues. We will probably leave the tube in for awhile. It sure makes oral dosing easy.

 

[Sharon14]

I'm glad he's feeling better. Sending prayers and vines for Leo, you and Theresa. You're doing a great job with him.

 

[JeffJ]

Updated status:

• Leo a bit subdued last 2 days.
• Ate a bit of food, mostly tube-fed.
• He will get abdomen stitches out next Mon or Tue.
• There is a small infection at the tube entry, we cleaned it and are doing daily cleaning and ointment.

Met with vet, for ~30 minutes. She is a dedicated vet and spent time with us to review Leo's future health and treatment. Summary:
- Prednisolone to start, we'll see how that goes
- Chlorambucil - we'll do the EveryOtherDay (EOD) regimen
- Cerenia to start for nausea
- B12 weekly injections (at home) starting this week

Chlorambucil is ordered. Will start treatment regimen probably Monday. We discussed Pulsed Dosing Method. The vet verified EOD regimen with the vet network and an internist. She does not want Leo's white blood cell count or bone marrow to be affected.

She told us expectations are to see some improvement in 2-4 weeks. If no improvement in 6-8 weeks, then he may be too advanced. He has SCL in - intestines, lymph gland, pancreas.