? New, struggling with diabetes and small cell lymphoma

[aleahmora]

Hi! I am new here and new to dealing with diabetes. Luna was diagnosed with diabetes in June this year, then diagnosed with small cell lymphoma just 3 months later (9/16). It's been a journey and we're still figuring everything out, wanted to see if anyone had any advice.

Background:
In 2020 at just 5 years old Luna was 'diagnosed' with suspected IBD via ultrasound after frequent daily vomiting. We have since been treating it with prednisolone and mirtazapine daily and was doing just fine, other than being mildly underweight (6.5-7lbs when she should be closer to 7.5, she is very petite).

After being diagnosed with diabetes this year, we decided to try senvelgo first to see how it would go. It was very touch and go. We tried bexacat too, but ultimately we couldn't fight the diarrhea & low appetite, even though her BG numbers were great. Because of the diarrhea, we decided to do an actual endoscopy for the suspected IBD/SCL, and turns out she actually has small cell lymphoma. sigh.

She now has a freestyle libre placed just for now as we figure out the insulin. We got a 2nd one placed because she just recently started chlorambucil 1.75mg every other day for the small cell lymphoma (see my spreadsheet for all my notes) and we've been struggling with her low appetite. We may ask to switch her to the every 2 week method but her vet appt is not until 10/17 and my vet is out of town for a few days.

She was doing fine when she was on insulin only (though her numbers were still all over the place), at least she was eating. After about a week of chlorambucil she hardly wants to eat. I have always felt like she strongly associates her food with her not feeling well and I have frequently had to make changes to her diet. Now with her needing insulin it's just extra stressful, she's always been a grazer.
Her diet before all this was not great (royal canin PD dry/canned), and I know it needs to change but we're trying to just handle one thing at a time. She now refuses to touch her royal canin and I just got a bunch of low carb fancy feast and friskies to try to get her to eat something, and it's working a little bit but she still just kind of picks at it.

My vet recommended just doing a half dose (1/2u) if her BG is still 250+ but she didn't eat very much, which I have been doing. Tonight her BG read 215 (libre and handheld meter reading) and I'm afraid to give her insulin at all because of how little she ate (barely half a can of 3oz fancy feast), I am going to check her again in a little bit and see if she will eat more.

Other meds she gets: 4mg prednisolone and transdermal mirtazapine daily - I know the prednisolone is not great for diabetes but again, we're trying to do 1 thing at a time and not make too many changes at once. Currently I give 4mg cerenia 1 hr before chlorambucil, I may start giving it to her daily. I also need to ask my vet about zofran.

If anyone has suggestions for a) insulin dosing and b) getting her to eat or c) anything else, I would appreciate it. Thank you for reading.

 

[Sienne and Gabby (GA)]

Welcome to FDMB.

I'm tagging one of our members who has experience with lymphoma. @Wendy&Neko . Did your vet not recommend a biopsy? It's the only way to make a definitive diagnosis.

At this point, I wouldn't worry about giving the prednisolone. You can always adjust the insulin dose to accommodate the prednisolone's effect on the blood glucose numbers.

This is a link to a post on strategies to stimulate a cat's appetite.

Are you feeding Luna twice a day? If so, I wouldn't worry about letting her graze. In fact, it's a better strategy for managing her diabetes. We recommend that you feed several small meals throughout the the first half of the 12-hour cycle. Well, actually up to the point where your cat has her nadir (lowest point in the cycle). The insulin starts to wear off after nadir. The only time you typically don't want to feed is 2 hours before shot time (unless your cat's numbers are low are it requires you to intervene).

If there's still an issue with diarrhea, have you tried probiotics? S. boulardii is an excellent option for managing diarrhea. I'm also going to link a website of Raw Feeding for IBD Cats. I wasn't sure if the IBD was ruled out. However, a raw diet may be an option. The webpage had wonderful information on medications and supplements especially for treating diarrhea. The "Start Here" section also has a discussion of IBD vs lymphoma. They also have a Facebook group where you can get questions answered. If you haven't tried feeding Luna novel proteins, it may also help to address some of the GI issues. While I do not recommend FortiFlora as an effective probiotic, it actually can entice a cat to eat. It may be worth trying, as well.

Even with the reduced dose, Luna's numbers aren't bad. I would suggest getting a "before bed" test every night, though. You're still giving insulin and you want to make sure she's in safe numbers when you're asleep.

 

[Wendy&Neko]

Hello and welcome. I am on my third cat with small cell lymphoma. Only one, Neko was also diabetic. (and CKD and heart disease and...). Anyway, I have a couple suggestions to help with the nausea. First, get rid of the every other day dosing. The every two week dosing is less overall chlorambucil and gives them some time between chemo doses to recover. Neko was always off her food with the every other day dosing, and it wasn't until I insisted we switch to every two week that she had over a week between doses when she felt like eating. Neko was my second SCL kitty. At that point I had also switched SCL kitty number 1 to every other week and it was also much easier on me too having both cats on the same dosing schedule.

Second suggestion, and maybe you can do that before talking to the vet on 10/17 is to see if you can get a prescription for ondansetron. Ondansetron is way better than Cerenia in helping chemo nausea. You have to give it more often 3-4 times a day, but works way better. Cerenia is better if you have actual vomiting. You can actually give both, I did with Neko.

Third suggestion is a discussion with the vet about the possibility of switching to budesonide for the steroid from prednisolone. It depends on the kitty, but for some cats budesonide does not impact blood sugar. Some it does, for Neko it did not.

Did the vet say if Luna has IBD and SCL? That is what I am currently dealing with. If no IBD in the picture, you don't need to worry about diet.

 

[aleahmora]

Welcome to FDMB.

I'm tagging one of our members who has experience with lymphoma. @Wendy&Neko . Did your vet not recommend a biopsy? It's the only way to make a definitive diagnosis.

At this point, I wouldn't worry about giving the prednisolone. You can always adjust the insulin dose to accommodate the prednisolone's effect on the blood glucose numbers.

This is a link to a post on strategies to stimulate a cat's appetite.

Are you feeding Luna twice a day? If so, I wouldn't worry about letting her graze. In fact, it's a better strategy for managing her diabetes. We recommend that you feed several small meals throughout the the first half of the 12-hour cycle. Well, actually up to the point where your cat has her nadir (lowest point in the cycle). The insulin starts to wear off after nadir. The only time you typically don't want to feed is 2 hours before shot time (unless your cat's numbers are low are it requires you to intervene).

If there's still an issue with diarrhea, have you tried probiotics? S. boulardii is an excellent option for managing diarrhea. I'm also going to link a website of Raw Feeding for IBD Cats. I wasn't sure if the IBD was ruled out. However, a raw diet may be an option. The webpage had wonderful information on medications and supplements especially for treating diarrhea. The "Start Here" section also has a discussion of IBD vs lymphoma. They also have a Facebook group where you can get questions answered. If you haven't tried feeding Luna novel proteins, it may also help to address some of the GI issues. While I do not recommend FortiFlora as an effective probiotic, it actually can entice a cat to eat. It may be worth trying, as well.

Even with the reduced dose, Luna's numbers aren't bad. I would suggest getting a "before bed" test every night, though. You're still giving insulin and you want to make sure she's in safe numbers when you're asleep.

I sweat I posted this earlier but I forgot to click the button I guess
Thank you for your response!
Originally when she was assumed to have IBD we opted not to do the biopsy, as her symptoms were very well managed with prednisolone and mirtazapine (back in 2020). We did have a biopsy last month so she is confirmed small cell lymphoma. I am hoping this means she does not have IBD, and that all the friskies/fancy feast chicken I am giving her will not cause more upset... previously, she was eating duck only but now she won't touch it no matter what I put on top.
For her, the buffet method works best. Currently if I am lucky she will eat 1/4 of a 5oz can. I offer her food throughout the day but take it away 2hrs before shot time, and try to get her to eat as much as I can before insulin. Is that enough food for a full insulin dose? I am never quite sure. This AMPS she is 215 again after eating 1/4 can (around 50 calories) so I have not given insulin yet.
I keep having to offer her different foods (alternating between friskies chicken, turkey and fancy feast chicken, turkey, beef pates). The chlorambucil did not give her diarrhea when she first started getting it, but now that she stopped eating and I'm giving her all these different food she does have some runny stool, I will have to look into S. boulardii! We have fortiflora, sometimes she likes it sometimes she doesn't.

Thank you for affirming her numbers look okay, I am happy to see a lot of yellow, too. Now that she has a new libre I can keep track more but I will note to check before bed after it comes off, too.

 

[Wendy&Neko]

Fortiflora can work as a flavour enhancer, but isn't good for much else. A much better probiotic for GI issues is Visbiome. You can used s. boulardii and a probiotic.

As far as how much she need to eat, she does't need to finish all her food before giving the shot. Do you have an idea how many calories she needs per day? Neko needed about 220-230 a day to maintain her weight. She had some Maine Coon heritage so a bigger girl, around 14+ lbs. For her, that 50 calories would have been plenty enough for me to shoot. The Lantus typically doesn't onset, or start to work, until 2-3 hours after the shot. So you've got plenty of time for her to eat more.

 

[aleahmora]

@Wendy&Neko I appreciate your insights here! I am definitely going to ask about the every 2 week dose and ondanestron at our next appt. She was feeling a bit better yesterday and ate a whole 5oz can, but today she is back to refusing to eat I gave her another 4mg cerenia since that is what I have right now. All she has eaten is maybe half a churu. Today I'm working so it's difficult but at least I am at home, I will try to add some tuna or something throughout the day to entice her to eat.

The vet did not specify if she has both IBD and SCL or only SCL. How would they be able to check? We have done a couple ultrasounds at my regular vet's office, but the endoscopic biopsy was done at a different vet hospital so they are the ones that informed me of the SCL diagnosis, and did not say anything about IBD (but they are aware of the previous diagnostic guess).
I guess, I will see in awhile if all this chicken she is suddenly getting affects her at all. Stool is a tad runny but I am not surprised after a big diet change.

For her calories per day, since she is so little I hope for around 160 calories but she needs to put on weight, so more if I can. That is good to know so I will hope for maybe around 30-40 calories.

 

[Wendy&Neko]

The vet did not specify if she has both IBD and SCL or only SCL. How would they be able to check?

The biopsy report should identify which diseases are present. You should be able to get a copy of it.

With the Cerenia, try it two hours before chlorambucil and I would give it daily while she is on the EOD (every other day) dose. You can give up to 1 mg/lb of cat, so the larger dose may be better for her. When a cat feels nausea from chemo varies by cat. Current kitty (IBD and SCL), when she was still on chemo, was worst about 5 days after the dose. You might want to track nausea days compared to chemo days to see if you can see a pattern.

Are you giving mirtazapine as pill or the transdermal Mirataz? There is a study showing that the transdermal works on nausea in cats getting chemo.

Chicken and fish and beef are common allergens in cats. I kept a "vomit log" that tracked when, contents (food, bile, foam) and what protein she was eating then. It helped me isolate which proteins were on the bad list.

 

[aleahmora]

I will reach out to the vet and try upping the cerenia (currently only doing 4mg on chemo days), thank you for the suggestions. The report I have only says "Master problems - Small cell lymphoma", but I will see if vet has a more detailed report. I do give transdermal mirtazapine in her ear, once a day an hour or so before dinner/PMPS time, but I may try to give in the morning too if it will help her.

Luckily she has not been vomitting yet unless she is hiding it somewhere. I try to keep track but I have 3 other kitties so sometimes it is tricky!