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after chemo or mets: metronomics & other options
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Winnipeg
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19 August 2009 - 8:48 am
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Hi All

I know a few of you are considering what treatment to follow post chemo or if/when lung (or other) mets appear. Here are a few questions (apologies to Jerry who no doubt sees the world turning in circles on this website).

To my surprise, my oncologist indicated that the effects of metronomics are well-documented for humans (I'd probably have tried them anyway). Possibly relevant to Jack's post and current situation (one possible lesion in one x-ray), she indicated they are effective in cutting off the blood supply so lesions do not grow (when they are too large for chemo to get to cells in the core of the lesion), as opposed to chemo which helps to kill microscopic cells.(Yes, I know ALL of you knew the first point about cutting off the blood supply already.) So I do not understand why your vet would recommend carboplatin IF there is a visible lesion. This oncologist seemed to advocate using metronomics post-chemo, rather than wait until a met shows up.

1. Anyone else have information on that suggestion (start metronomics post-chemo and pre-met, or start them once mets show)

2. Some of you have mentioned potential problems (urinary infection, kidney) with metronomics. What are the risks?

3. Is there a limit to how long one can use metronomics?

4. How do you go about preparing a plan for metronomics? I know Jerry's plan is posted on the site (and would appreciate the link again), but did you develop it yourself or does a vet or an oncologist prepare such a plan?

5. Inhaled therapy sounds good and the oncologist was also receptive to that, although I don't think she would get involved (I do not understand how the interleukin 'gene therapy' differs from inhaled chemo, but that doesn't matter too much), but I assume that is specifically for mets that might or have appeared in the LUNGS. Certainly mets can show up elsewhere, e.g., spine or limbs, in fact, my oncologist indicated that was pretty likely in 'treated' (chemo) dogs and I happened to meet such a dog in the waiting room yesterday (choc lab, only 1&1/2 yrs old).

Any other treatments that specifically help avoid or treat mets that might show up outside the lungs, e.g., in the bones? I assume metronomics is good for any location of the body.

Susan & T2

p.s. I do not mean to ignore holistic options but am trying to restrict the topic here. I do want to ask Jack about some of those things she just mentioned (IP?)

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19 August 2009 - 11:18 am
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Tazzie said:

Hi All

I know a few of you are considering what treatment to follow post chemo or if/when lung (or other) mets appear. Here are a few questions (apologies to Jerry who no doubt sees the world turning in circles on this website).

4. How do you go about preparing a plan for metronomics? I know Jerry's plan is posted on the site (and would appreciate the link again), but did you develop it yourself or does a vet or an oncologist prepare such a plan?


Susan you don't need to apologize at all, promise, we're all about sharing information here and educating each other. We are always happy to help where we can.

Now I'm apologizing because I have to run to work for a bit, but here's some links that I hope help until I can get back here:

Here's the link to our blog post about My Metronomic Therapy, and one to a video follow up with Dr. Mullins

And a second blog post, "Options for Treating Osteosarcoma after Lung Metastasis"

Finally, Bone Cancer Dogs also has a good section about Metronomics.

Eeek! Running late, gotta go. Back later.....

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19 August 2009 - 12:36 pm
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Hi Susan.  We started Max on metronomics post-chemo, pre-lung mets.  He has been on them for about 16 weeks now.  He just had his check-up on July 25, and everything was good and clear.  His next check-up is September 12.  Our oncologist prescribed his specific medicines.  I don't have the mg's with me currently, but he initially started off with a daily dose of Cytoxan (the actual chemo pill), Piroxicam and Actos.  After 8 weeks, he changed from Cytoxan to Leukeran (one pill every other day), still taking the Piroxicam and Actos daily.  I just mix everything in with his meals.  Max has not had any problems thus far with the medicines. 

I don't remember the name, but I should also let you know that a 4th medicine was prescribed when Max was taking Cytoxan.  Apparently Cytoxan can cause crystals to build in the bladder (I think?), making urinating painful.  So Max had to take a 4th medicine, which would stop the crystal buildup so he wouldn't have any trouble peeing.  And he never did. 

Also, from what our oncologist has told us, metronomics is full time; no breaks like with chemo.  It's a daily dose for as long as your pup can take it. 

I apologize for not having the correct dosages and names, I'm at work right now and all that stuff is at home.  Anyway, hope this answered some of your questions.

Di

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19 August 2009 - 12:45 pm
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I think that it makes the most sense to start metronomics before lung mets develop.  Most oncologists use a chemo drug plus an NSAID and some still add the antibiotic doxycycline although that seems to be out of favor right now.

The 2 most common NSAIDS used are piroxicam and Metacam (meloxicam).  The main side effect is on the GI tract so watch for vomiting and you also have to monitor liver and kidney values.

The 2 most common daily chemo drugs used are CCNU(lomustine) and Cytoxan(cyclophosphamide).  Daily use of Cytoxan can predispose to bladder infections or cause a sterile hemorrhagic cystitis (bloody painful urination).  CCNU is most likely to affect the liver or bone marrow.

I tried Cytoxan with Tazzie but had to stop after 6 weeks due to a bad bladder infection.  She still gets the meloxicam daily.  My other dog Kona has intestinal cancer and I tried the daily CCNU but after 8 weeks her liver enzymes became too elevated so I had to stop that so my luck with metronomics has not been great!  I think that it is worth a try.

I started artemisinin after Tazzie's carboplatin was complete and she has had no side effects from that.  I also had her on a Bone Stasis powder (chinese herbs) to help prevent bone mets but Tazzie started refusing her food when the herbs were mixed in so we stopped that a few months ago.

Pam and Tazzie

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19 August 2009 - 1:09 pm
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Thanks maximutt and tazziedog - that is a big help in getting started.

1. Tazziedog - did you wait until after traditional chemo to start metronomics, or does that depend on the 'pill' (I assume the chemo drugs, cytoxan, are best delayed until regular chemo is done - is that right - whereas other things like NSAID can be started earlier.)

2. As for doses of metacam, do you use the same dosage as you use for pain control, or a reduced dose? That is something I'll probably do now, as long as he is not suffering nausea.

So sorry about Kona - there is too much cancer in your family right now!

S & T2

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19 August 2009 - 4:26 pm
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Hi Susan & T2:

We started metronomics pre lung mets/post chemo. Although it didn't delay the lung mets like we hoped. The oncologist was very encourage on how SLOOOOOOW they were growing.

The IL-2 therapy (BTW-what we use is not the actual 'gene' because you cannot buy that for home use) but it is a lab-created equivalent, so I guess the term the oncologist says is: Immunotherapy.  (Uh, yeah, okay, whatever, as long as it works).  The one thing about IL-2 is that you need to make sure that you and the dog are prepared/able/willing to commit to 2x/day for 15-20 minutes.  

Thankfully, Tika is laid back (well, except around a water dish, eh Colorado TriPawds?Blush)  and will just lay peacefully while we nebulize her. We have just spent the last 6 days in a camper and still continued with the treatment.  Uh, and yes, things do not nebulize as fast at 8500 ft. Eleven days until we find out if it worked!!!  

As far as the protocol.  Tika sometimes has issues with the Piroxicam and will vomit.  Not reaction to the Cytoxan.  We give her sulfacrate (stomach protectant) in the morning to help with that. We started the Piroxicam right before her last Chemo and then the Cytoxan a week or two after.

Take care, hope you are doing well!

Kim

Kim and Spirit Tika http://www.tika.....ogspot.com

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19 August 2009 - 10:34 pm
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Tazzie 2 you can start the NSAID anytime, assuming that he is not vomiting from the chemo.  We started the chemo pill 3 weeks after the last dose of carboplatin.  The dose of NSAID is the same as that for pain.  My Tazzie takes 7.5 mg meloxicam once daily and she handles it really well.

Pam and Tazzie

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23 August 2009 - 9:28 am
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When I think about it, I feel overwhelmed at the number of potential leads we have for treatment options, particularly when we want to focus on our dogs and not their cancer. Jack's IP6 sounds as though it has great promise, and probably one I'd like to pursue, but that link showed me other things that came up on this website the last couple of months.

Thankfully, I just looked up Jerry's link to the post-lung mets chart he posted above - I was just thinking how great it would be to have a summary of treatment options, including when they are appropriate and what can be done with other treatments, although I know I would not make the time to do that. So that chart is a huge help. Can we extend it a bit to include pre-mets, so that we consider treatments that work on mets that can appear outside the lungs (bones, spine)? I assume metronomics would be equally applicable to all locations.

In any case, a MOUNTAIN OF THANKS to all of you who have done a great job talking to oncologists and tracking down promising leads - Jerry, Jack, Tazziedog, Tika - thanks to maximutt for a nice description of your metronomics protocol.

A few specific questions:

1. Jack - did you begin IP6 and inositol during chemo? I guess so if you are still on chemo, and the pdf paper sounds as though it is complementary to chemo. How did you figure out a dose for Jack - did your vet get involved? Where did you get IP6 and when did you start this?

2. Tazziedog - did you begin or can one begin artemisinin during chemo? And how do you calculate the dose? Didn't you also mention "power mushrooms" in an earlier email?

It sounds as though it is safe to use the following drugs (or herbs) at the same time: for now the potential list includes traditional chemo (adriamycin & carboplatin), metacam, IP6 and artemisinin? Is that right?

Susan and Tazzie 2

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23 August 2009 - 10:32 pm
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It is okay to start artemisinin during chemo but I chose to wait, only because I didn't want to overload her with too many things at once.  I emailed Dr Cuoto at OSU and also one of the human docs at UW Seattle to determine Tazzie's dose.  The dose of artemisinin is 200-300 mg per day per dog given 3-4 hours after dinner.  It can't be given with food that contains iron so we give it with cheese. Artemether dose must not exceed 0.5 mg/pound/day since it is a stronger compound. We gave it daily for 8 weeks but now do 4 times weekly since we are still in prevention mode.  Any dog with lung mets should probably take it daily indefinitely.

I wish that we had started Power Mushrooms sooner!  I did not use K9 immunity only becauseTazzie would need 18 caps per day and the cost would have been extreme.  Our holistic vet recently told me about the mushrooms made by Health Concerns and a bottle of 270 costs only $39.95 including shipping.  There are many online companies that carry this product but I found a good price on a site called Acupuncture Atlanta.  Tazzie gets 3 tabs twice daily.  My other dog Kona also has cancer and she weighs 65# so she gets 2 tabs twice daily.  This bottle lasts me a month for the 2 dogs and they both seem very peppy and happy.

Pam and Tazzie

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24 August 2009 - 6:24 am
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Yes, we learned about IP6 and Inositol about 3 weeks ago.  While at the oncologist for a chemo treatment, I happened to get the e-mail about this supplement, so I just asked our doctor then and there.  I went to the supplement store and found, to my surprise, a bottle of tablets already combining the 2 therapies.  A bottle of 120 tablets is $25.50.  I read somewhere that for existing cancer, a recommended dose of 5-8 grams of IP6 should be given, and with 800mg per tablet (with a dosage of 2 tablets twice daily), Jack gets 3.2 grams of IP6 and 1 gram of Inositol.  The dosage was for human patients, so for a little doggy, I figure this dose was fine.  He has been on the therapy for about 2 weeks, but I stopped giving them to him for a few days at the beginning since his personality got all weird.  Inositol is also a treatment for OCD and ADD, so when I first gave them to Jack, he got like, all determined and focused and would act like he couldn't sit still and he would pee like, 3-4 times per day for a loooong time when he usually only goes twice.  So I just stopped for a couple days then eased him back into it with 1 pill daily, then 2 pills daily, then 3, and now we are at our regular dosage of 2 in the morning, 2 at night.  If you start Tazzie on this, just be sure to watch how he acts on it because you may need to taper off for a couple days to get him used to it.  The power mushrooms Tazzie1 talked about sound awesome!  I think I'll get some.  We had Jack on K9 Immunity, but he gets 4 caplets a day and 2 bottles of that plus one of transfer facter cost us well over $150 for a month.

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24 August 2009 - 7:55 am
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It sounds as though we are making Super Dogs with Power Mushrooms and IP6 that makes the dogs determined, focused and restless. A bit scary I think! K9 immunity is rather expensive, isn't it?! But perhaps we should not use K9 immunity and power mushrooms together (???)

Tazzie 2 will start to get fat - currently each pill means a chunk of meat wrapped around the pill. I don't think butter is any lower in fat.

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24 August 2009 - 12:36 pm
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My Tazzie did put on weight from all of that cheese! She went up to 194 #.  We have since adjusted her diet and she is back around 185#.

You are right, Power Mushrooms would be used instead of K9 Immunity.

Pam and Tazzie

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28 August 2009 - 11:06 am
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Bisphosphonates: zoledronic acid:

A vet tech friend sent me a short article today on "Bisphosphonates" (and specifically "zoledronic acid). These seem to be used for local tumor control. On the tripawds website, I see one mention of the bisphosphonates used by a dog Timber that had tumors in two legs, about 1 yr ago. He used them in addition to metronomics.

Anyone familiar with these? Are they sometimes used after lesions show up (or in dogs that do not have an amputation)? They mention an oral form, every 28 days, or an injectable form that might last for 4-6 months.

In the article, they describe one case of a 10 year old dog, right fore leg lame, that showed 'stable non-metastatic disease' for 16 months, even though the primary tumor did enlarge. They found a prescapular mass after 16 months, at which point they stopped therapy. So I am guessing that spread might have been related to the primary tumor (it gives the reference for the original article, but I don't have that one).

Susan

Zoledronic acid for the treatment of appendicular osteosarcoma in a dog. Spugnini, EP, Vincenzi, B, Caruso, G, et al. Journal of Small Animal Practice 50: 44-46. 2009

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28 August 2009 - 11:15 am
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We haven't heard of it in relation to dogs, but if anyone has, please start a new thread in this Forum to make it easy for others to find. Thanks!

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28 August 2009 - 12:52 pm
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Pamidronate is the bisphosphonate most commonly used for OSA and is usually given IV to delay local bone destruction if amputation is not done.  I would try it if cancer came back in another bone.

Pam and Tazzie

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