scott@vtx-cpd.com

Hi Emma,

Thanks for sharing the case. Framed purely around comfort and quality of life rather than disease modification, I think much of what you are already doing is very appropriate. Increasing prednisolone closer to a true palliative lymphoma dose in the region of 1.5 to 2 mg/kg/day is entirely reasonable at this stage, particularly given the fairly rapid progression of peripheral lymphadenopathy. This may provide some short-term cytoreduction with improvement in comfort, appetite, and general wellbeing, although I would be clear with the owners that any benefit is likely to be transient and measured in weeks rather than months. Despite the existing PU/PD, proteinuria, and mild azotaemia, I would not withhold escalation of pred purely on that basis if she remains bright and engaged, although increasing the dose cautiously and reassessing clinically is sensible.

The progressive, non-regenerative anaemia is very consistent with anaemia of chronic disease, possible bone marrow involvement, or cytokine-mediated suppression associated with lymphoma. Unfortunately, there is very little that reliably improves this in the absence of chemotherapy. Cobalamin supplementation is reasonable but is unlikely to meaningfully affect the PCV, and I would generally avoid iron supplementation unless there is clear evidence of deficiency, as it is rarely helpful in this context. While anaemia of chronic disease is the most likely explanation, I do think it is reasonable to keep an open mind about other contributing factors, particularly marrow infiltration or less commonly immune-mediated mechanisms, even though identifying these does not substantially change management in a palliative setting. I have occasionally considered darbepoetin in neoplastic cases, but in lymphoma the evidence for benefit is very limited, and the risks, costs, and logistical burden usually outweigh any potential short-term gain, so I would not routinely pursue this as part of palliation.

With respect to the kidneys and proteinuria, starting benazepril with a persistently elevated UPC above 5 is entirely appropriate. I would keep expectations modest regarding any improvement in the UPC, but ACE inhibition may help slow further renal decline and can indirectly support comfort. Monitoring blood pressure if feasible is worthwhile, as hypertension can accompany both proteinuric renal disease and neoplasia. I would avoid aggressive dietary protein restriction unless there are clear clinical signs of uraemia, as maintaining appetite, caloric intake, and body condition is usually the higher priority in a palliative context.

Weight loss and muscle wasting are unfortunately very common in multicentric lymphoma and often progress despite a reasonable appetite. I would prioritise calorie-dense, highly palatable foods over any attempt to adhere to idealised renal or oncology diets. Low-dose mirtazapine can be helpful not only for appetite but also for nausea and overall demeanour, even when intake seems subjectively acceptable. Omega-3 supplementation may offer mild anti-inflammatory and cachexia-modulating benefits, although expectations should remain realistic.

In terms of additional supportive care, I do not routinely use omeprazole simply because a dog is on steroids, but if the prednisolone dose is increased, or if there are concerns about gastrointestinal comfort, nausea, or appetite consistency, then acid suppression can certainly be considered on a case-by-case basis. Analgesia is worth considering proactively even in the absence of obvious pain, as marked lymphadenopathy and visceral involvement can be uncomfortable. Low-dose gabapentin is often well tolerated, including in dogs with mild renal compromise, and can improve overall comfort and demeanour. Anti-nausea medication can also be helpful if there is any suggestion of nausea or food aversion developing. Appetite stimulants can play a role as the disease progresses and cachexia becomes more prominent. Mirtazapine is generally my first choice in this context. I am more cautious with capromorelin, as stimulating appetite does not necessarily counteract cancer-associated cachexia and can sometimes lead to frustration if increased intake does not translate into weight gain, but it can still be considered if appetite itself becomes a limiting factor for quality of life.

Overall, I think your current plan is entirely appropriate. Increasing prednisolone, continuing ACE inhibition, and layering supportive and comfort-focused care is realistically as much as we can offer without chemotherapy, and while further improvement in blood parameters is unlikely, maintaining her current brightness and enjoyment for as long as possible is a very reasonable and compassionate goal. From a practical standpoint, if the owners wish to pursue something beyond steroids alone but still avoid full chemotherapy, chlorambucil in combination with prednisolone is the most practical and commonly used metronomic option for multicentric lymphoma, offering the best balance of tolerability and potential benefit. Cyclophosphamide-based metronomic therapy is an alternative but requires more caution, particularly in a dog with proteinuria and renal involvement.

Hope that helps!

Scott 🙂

Hi Joanne,

The introducers/tunnelers you’re seeing (MILA ETUN14, ETUN18, etc.) are only for large oesophagostomy tubes (10–30 Fr). They cannot be used for the small 4 Fr and 8 Fr tubes I recommended earlier.

4–5 Fr and 8 Fr tubes = nasal tubes
→ These are placed directly through the nostril and do NOT need an introducer.
→ Just order the tubes themselves.

10–14–18–20 Fr tubes = oesophagostomy tubes
→ These do require a tunneler/introducer, and that’s why the sizes start at 12 Fr and up.

So in short:

Yes, your clinic can order 4 Fr and 8 Fr tubes — no introducer needed.

The introducers you found are for a completely different type of feeding tube (E-tubes).

You only need a tunneler if you plan to place oesophagostomy tubes, not nasal tubes.

For reference, here is the product link you found (for the oesophagostomy tunneler):
https://www.milainternational.com/products/esophagostomy-feeding/tunneler-for-length-adjustable-esophagostomy-feeding-tubes.html

I have popped a MILA discount code below.

Scott 🙂

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