Jump to content

Fast Help Needed Re Switch From Pred To Budesonide


greyhead
 Share

Recommended Posts

A Japanese friend has an older grey with intestinal cancer that has spread to the spine. He's going in for chemo in an hour or so. The oncologist has finally consented to try budesonide, which I'd recommended when it looked like he had IBD. Since budesonide targets the GI tract, maybe that's not a bad idea, even though it's now cancer. But he has been on prednisone for a long time, and this oncologist is proposing to start the budesonide right away. I'd heard here that a two-week wash out period would be required between the two meds. My friend mentioned this to the vet, but the vet said that she hasn't seen anything in the literature to that effect.

 

My Japanese friend loves her dog dearly. She even came back here from Japan to get better treatment for her dog than he was getting there! But she's very polite, not at all argumentative, and isn't sure how to get the oncologist to back off.

 

The dog has lost a lot of weight and now can't even get up without assistance, I think. So perhaps being off pred for two weeks and without anything else is not a good idea, which I told my friend. But she's afraid that she can't explain to the vet why she no longer wants to switch from pred to budesonide. So can any of you point me to anything, anecdotal or otherwise, that my friend can use to support her position? She's desperate, and I'm desperate to help her.

 

Many thanks, and please hurry,

Mary

Edited by greyhead
Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

The closest I can get is a study of patients with inactive Crohn's disease who were switched from prednisone to budesonide. They tapered the prednisone over weeks, and even then some of the Crohn's disease patients suffered relapses. Not really close, but it shows they didn't leap from one med to the other. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1728198/

 

ETA: It appears patients took both meds at once, tapering down the pred while increasing the budesonide to compensate.

Edited by KF_in_Georgia

15060353021_97558ce7da.jpg
Kathy and Q (CRT Qadeer from Fuzzy's Cannon and CRT Bonnie) and
Jane (WW's Aunt Jane from Trent Lee and Aunt M); photos to come.

Missing Silver (5.19.2005-10.27.2016), Tigger (4.5.2007-3.18.2016),
darling Sam (5.10.2000-8.8.2013), Jacey-Kasey (5.19.2003-8.22.2011), and Oreo (1997-3.30.2006)

Link to comment
Share on other sites

Thanks, Kathy. IIRC, you don't just stop pred all of a sudden, you always taper it, right? So if the oncologist is proposing to start budesonide immediately, the dog has to continue on the pred while tapering, yes? (The budesonide has already been ordered and is arriving today.)

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

Friend is at the oncology office now but doesn't know how soon she'll be seen. The dog will get chemo. She asked if she could have the oncologist call me, if only so I can help my friend understand what the vet is saying. I said sure. Yikes.

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

Did a quick search-not much info on making the switch between the two corticosteroids--however, I do believe you need to wean down the pred to a low enough dose before starting up on the budesonide. To be completely honest though pred is often used in conjunction or as a chemotherapy agent. With know cancer in the spine I'm not sure why you would want to switch now. Do youmknow what type of cancer this dog has??

Link to comment
Share on other sites

Thanks, Tracy. I don't know what kind of cancer it is, but I know what you mean and I had the same question. (My friend's English is somewhat limited, so I try to just deal with whatever concern she presents me. She knows I have no cancer experience, so we've never gotten into the specifics of that, especially since I'm not sure that even she knows.) It appears that maybe this cancer is the kind that morphs from IBD and then spread, but I'm guessing.

 

My friend just called -- we'll call her S. here -- and the conversation with the vet went well. Turns out the vet isn't intending to just switch abruptly or to give them both at once. She intends to taper the pred. Now that she realizes how upset, uncertain, and overwhelmed S. is, the vet is going to call several other oncologists and ask their advice about how to best make the switch. The reason for the switch, in the vet's mind, is that the pred has done no good whatsoever, as far as she can tell, and there's nothing to lose at this point in trying another approach. (Why do they always wait until the 11th hour to try budesonide?!) She did say that the dog doesn't have much time left.

 

So the vet has ordered the budesonide, it will arrive at her house from the pharmacy tomorrow, but S. doesn't know what dose is ordered. I told her it should probably not be more than 3 mg., and 2 might be better to start with, but whatever. I told her about Spencer's tongue swelling alarmingly the one time we tried 4 mg. for a flare early on, so she'll be on the lookout. The vet will let her know ASAP what her other oncologist friends have to say.

 

Thanks so much for the help, Kathy and Tracy. S. loves this dog more than life and is beyond grateful for any and all help. :bighug

Edited by greyhead
Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

Texted S. to inquire about the cancer, and she said it's small-cell lymphoma in the intestine. She added: "But there's also sign of cancer with spine just found out also, can be lymphoma or another kind." I know the intestines were biopsied, but the spinal thing is brand new. I hope the "sign" is really something else!

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

Okay, just got an email from S. that she sent 30 minutes ago. I'll just copy it here:

 

"The doctor came back with direction for switching the meds.

"She said to decrease predonizone 20mg/day to 10mg/day starting from today for 5 days, the predonizone will be stopped, but get him on Budesonide 2.8mg/day starting right away at the same time.

"I thought they never should be given at the same time, and told her I'm not comfortable with it.
Then she became pretty aggressive and telling me its my choice following her instruction or to my friend (which is you), such & such that I really felt uncomfortable.

"Telling her that I'm not even trying to argue with you, and why she has to be aggressive.
I think she was offended, but what can I do except being honest and tell my feeling to it.


"Anyways, she said it's okay if to reduce predonizone for 10mg/day for 5days, and not starting the Budesonide till after 5days stopping with predonizone, if that will make me feel better.

"Do you think it's better waiting for 5days instead of start given at the same time, like how I feel??"

 

I said I'd start decreasing the pred, as instructed, but wait at least a couple days before starting the budesonide, just to give herself time to think (and for me to ask your reactions)! It's so weird because when we talked earlier, she sounded so relieved because the vet had sounded so on-the-same-page (as in never, ever give those two meds at the same time)!

 

So, any thoughts about what she should choose?

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

The Crohn's study--which of course was people, not dogs--gave both at the same time: tapering down the prednisone while slowly building up the budesonide (or the placebo) at the same time.

15060353021_97558ce7da.jpg
Kathy and Q (CRT Qadeer from Fuzzy's Cannon and CRT Bonnie) and
Jane (WW's Aunt Jane from Trent Lee and Aunt M); photos to come.

Missing Silver (5.19.2005-10.27.2016), Tigger (4.5.2007-3.18.2016),
darling Sam (5.10.2000-8.8.2013), Jacey-Kasey (5.19.2003-8.22.2011), and Oreo (1997-3.30.2006)

Link to comment
Share on other sites

The Crohn's study--which of course was people, not dogs--gave both at the same time: tapering down the prednisone while slowly building up the budesonide (or the placebo) at the same time.

 

AFAIK that's the standard way to do it. It's not like NSAIDs. Plus, the current prednisone dose is quite low.

Star aka Starz Ovation (Ronco x Oneco Maggie*, litter #48538), Coco aka Low Key (Kiowa Mon Manny x Party Hardy, litter # 59881), and mom in Illinois
We miss Reko Batman (Trouper Zeke x Marque Louisiana), 11/15/95-6/29/06, Rocco the thistledown whippet, 04/29/93-10/14/08, Reko Zema (Mo Kick x Reko Princess), 8/16/98-4/18/10, the most beautiful girl in the whole USA, my good egg Joseph aka Won by a Nose (Oneco Cufflink x Buy Back), 09/22/2003-03/01/2013, and our gentle sweet Gidget (Digitizer, Dodgem by Design x Sobe Mulberry), 1/29/2006-11/22/2014, gone much too soon. Never forgetting CJC's Buckshot, 1/2/07-10/25/10.

Link to comment
Share on other sites

Purely from a human standpoint (bone marrow transplant), we often give budesonide and prednisone concurrently. Budesonide is working only on the gut, while we need systemic steroids for other reasons (often long term). With spinal metastasis, I'd be concerned about tapering the pred too quickly.

Link to comment
Share on other sites

I didn't think so, Tracy. They used pred exclusively. Then he had a flare much later, and then they may have tried budesonide.

 

Thanks for the input, Kathy and Jey. I wasn't comfortable relying on the human Crohn's experience, but it would be a relief if this doesn't have to be handled like NSAIDs. On the other hand, I don't think there's a lot of experience with these meds in greyhounds. The only thing is, I distinctly recall a hound passing away from IBD last spring when both pred and budesonide were given at the same time. That poor dog was in bad shape before the budesonide was added, but a couple people here said they shouldn't be given simultaneously. One was Burpdog, but she hasn't responded to me on this.

 

ETA: Thanks Meghan. You posted while I was writing. I share your concern about the spine. And I guess human experience is what she might have to go on.

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

...

She did say that the dog doesn't have much time left...

 

S. loves this dog more than life and is beyond grateful for any and all help. :bighug

I can't give any advice on how the pred and budesonide should be given I just pray your friend doesn't try so hard to save her dear greyhound she waits too long to let her go like I did. People think osteo is bad, I'm sorry but it doesn't hold a monopoly on pain compared to what lymphoma can do. The saying "better a day too early than a day too late" isn't enough. If I had had the slightest idea what those last hours would turn out to be like I would have let her go weeks before and saved her the horror of that night.

Link to comment
Share on other sites

I'm so sorry, Judy. Thanks so much for saying this, as hard as it must be. I'll make sure my friend hears it, and I'm sure she'll take it to heart.

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

Purely from a human standpoint (bone marrow transplant), we often give budesonide and prednisone concurrently. Budesonide is working only on the gut, while we need systemic steroids for other reasons (often long term). With spinal metastasis, I'd be concerned about tapering the pred too quickly.

 

This.

 

I'm posting privately to Mary with more detalled info from the literature, but there are few EBM veterinary studies and the ones that I can find have small cohorts so are not as reliable. There are no specifics on exactly how quickly to transition from systemic steroids to budesonide. But the common denominator in all of the human and veterinary studies that I reviewed is that the budesonide is started concurrently with the beginning of the systemic steroid taper, to reduce the risk of hypothalamus-pituitary-adrenal axis suppression and other steroid sequleae. And the steroid taper is tapered more gradually (not over 5 days) as the budesonide is titrated up. This is suggested in human literature in the treatment of Crohns, and is what many of the vet studies mirror.

 

Sadly, I'm sure the pred is being given purely for palliation, not with the intent of cure or even remission. He has Stage V disease with probable spinal mets which carries a very grave prognosis. I hope she can accept this and do what she can to keep him comfortable and happy. :huh

gallery_13500_3426_13848.jpg

Link to comment
Share on other sites

I'm not sure if they know what type of cancer is in the spine-one would assume its a met, however, there could be two types of cancer here. I believe the pred was given chronically to treat the IBD. I am still confused as to why you would want to start the budesonide now that a stemic corticosteroid would be more benefical a this point. I'm sure there are pieces of the puzzle we are not privy too.

Link to comment
Share on other sites

The reason for starting budesonide, as I understand what I've been told, is that the oncologist says the pred isn't doing any good at all.

 

Jordan PM'd me some very helpful info. I'm thinking I'll tell my friend she might as well go ahead with the oncologist's plan but have meds on hand for severe pain and a plan for the end.

Mary with Jumper Jack (2/17/11) and angels Shane (PA's Busta Rime, 12/10/02 - 10/14/16) and Spencer (Dutch Laser, 11/25/00 - 3/29/13).

Link to comment
Share on other sites

I'm so sorry, Judy. Thanks so much for saying this, as hard as it must be. I'll make sure my friend hears it, and I'm sure she'll take it to heart.

Thanks. Everytime I read about another lymphoma case I feel sick knowing what they can be facing. Please relay my heartfelt condolences to your friend for the decision she's going to have to make.

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

 Share

×
×
  • Create New...