Sebastian is Back at the Vet...Suspected Pancreatitis Again :(

:nod: Of course I understand. I sure hope they have them!

I do so much shopping on Amazon, I'm a "Prime" member, so even overnight stuff is $3.

Unfortunately, I couldn't find the gel caps last night after calling a few places. Looks like I'll have to buy them online. I had to give him the Mirtazapine last night in its raw form, and it was the same struggle. He foamed most of it out and refused to swallow. I guess he ingested some of it because he was very vocal through the night. He refused his usual wet food and dry kibble, but he did eat some Stella & Chewy's freeze dried raw last night and some Wellness Chicken canned this morning.

Anyway...an update:

When the doc called me last night for an update, I told her where we stand at home - that he hasn't eaten on his own since Monday night until given the Mirtazapine. However, the Mirt is only masking an issue, so she wanted me to bring him in this morning. Off to the vet we went again. We discussed next steps and talked about a biopsy. Doc explained the two ways to do a biopsy, and I decided against it. I think it will be too invasive for my fragile boy, and whether it was IBD or lymphoma, the treatment would be the same ( I probably wouldn't pursue chemo if it was cancer). If his health continues to decline dramatically, I suppose we can assume that its cancer. 

Here was the doctor's recommendation and I want to see what you all think. She wants him to be on a novel protein diet like rabbit, but the transition to this is not going to be quick enough for the treatment he needs for the inflammation right now. So she wants to start him on 7.5 mg of prednisolone for one week, then taper down to 5 mg for the next week, and then see where we are. She did say its possible that pred can aggravate pancreatitis, so she did a quick, in-house ultrasound on his pancreas to see if it was enlarged or thickened first. It appeared to be normal. When I mentioned a 2.5 mg maintenance dose, she thought that was so low to even bother, but I know people on here have had success with a small maintenance dose.      We also talked about the side effects of pred, and I will consider a liver/kidney support supplement (I forget which organ is affected by pred). 

I left the vet with a prescription for prednisolone and Royal Canin Hypoallergenic Rabbit in both dry and canned. Now I know what we all say about these prescription diets, and the dry in particular is very high in carbs, but we have to start somewhere, right? When I mentioned other brands of novel proteins, such as Hound & Gatos and Addiction, she groaned. I asked her to explain her frustration. She cited the studies (which I've read) that have found traces of beef, chicken, etc. in canned foods. I asked why does this not apply to Royal Canin, and she said she trusts their strict quality control. I had no argument there because I know nothing about RC's quality control. She also wants me to give him 1/4 tab of Pepcid daily (more reason to get those gel caps) and sub-q fluids every other day.

I hope I didn't leave anything out. Thoughts?

To stabilize him, I see absolutely no reason not to do this. I personally would try to skip the dry food altogether. But he needs to eat. I mean - there's definitely a point where that he eats is more important than what he eats.

Of course, given that he liked the S&C rabbit, I'd contact the company (they have great customer service) to ask about the possibility of other proteins in minute amounts being in their rabbit formula.

The main side effect that can come from long term steroid use is diabetes.  Patches was on 10 mg a day when he was really sick and then he was cut down to 5 mg.  Now that I think about it he did stay on the 5 mg a day until the vet couldn't get the pred anymore.  I don't know how the pred dose translates to the dex.  When I looked it up online I found out that it is a much stronger steroid than the prednisolone.

I do know that you want the prednisolone and not prednisone.  The liver actually turns the prednisone into prenisolone so it's harder on the liver and you end up with the same medicine.  

When Patches was on Flagyl the vet gave me the gel caps.  She, well actually probably the vet tech, cut up the pills and put them in the gel caps for me.  The two mild flares he has had since she gave him the flagyl again and I got them cut up in the gel caps.  I didn't get the biopsy done we just went on the assumption that it is IBD.  

I know others here have their cats on 2 1/2 mg a day and some give it every other day.  Patches has always gotten it daily.

LDG said:

To stabilize him, I see absolutely no reason not to do this. I personally would try to skip the dry food altogether. But he needs to eat. I mean - there's definitely a point where that he eats is more important than what he eats.

Of course, given that he liked the S&C rabbit, I'd contact the company (they have great customer service) to ask about the possibility of other proteins in minute amounts being in their rabbit formula.

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I agree. I've been trying to get him off dry food, but every time I make some kind of progress, he tanks again and I have to give him whatever he will eat.  The good news (kind of) is that after we got home from the vet (which was not until noon and I was super late for work), I put down a tablespoon of the RC Rabbit dry and he ate it all.

Yes, I am going to make some calls to various manufacturers of rabbit and see if there are traces of other proteins in their formula.

Denice said:

 
The main side effect that can come from long term steroid use is diabetes.  Patches was on 10 mg a day when he was really sick and then he was cut down to 5 mg.  Now that I think about it he did stay on the 5 mg a day until the vet couldn't get the pred anymore.  I don't know how the pred dose translates to the dex.  When I looked it up online I found out that it is a much stronger steroid than the prednisolone.

I do know that you want the prednisolone and not prednisone.  The liver actually turns the prednisone into prenisolone so it's harder on the liver and you end up with the same medicine.  

When Patches was on Flagyl the vet gave me the gel caps.  She, well actually probably the vet tech, cut up the pills and put them in the gel caps for me.  The two mild flares he has had since she gave him the flagyl again and I got them cut up in the gel caps.  I didn't get the biopsy done we just went on the assumption that it is IBD.  

I know others here have their cats on 2 1/2 mg a day and some give it every other day.  Patches has always gotten it daily.

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Oh, I forgot that! The vet did say that diabetes is a side effect. And yes, I did get prednisolone. The vet wanted to start him at 10 mg, but I wanted to do 5 mg, so we met in the middle. 

That's another thing I forgot! I think they did give him some Flagyl while at the vet, but I don't remember seeing it on my receipt. Hmm...I'll check on that when I get home. Maybe she decided not to give the Flagyl since we started his first dose of pred today.  Do those two things counteract each other?

  Re diet:  What about  Nature's Variety ,  at least the canned.   I think  that would be lower carb.    My cat's internist (a DACVIM)  recommended the canned NVI  in a novel protein as something that would be lower carb than the "prescription" food.   

 I think their rabbit may be from China  but they also have venison or lamb.    The rabbit and the venison have pork liver.  but maybe that is novel to him too?   The lamb has only lamb . 

Louis ate the venison and did very well on it.    ( and i saw what happened when he got into some other food with beef  and had bloody vomit and diarrhea which he never had on the NVI venison)    

 Unfortunately,  their dry foods all have chicken meal included except the Limited Ingredient ,  but that's got turkey.    

 ( Louis was already diabetic  which is why the vet was more concerned about the carbs with him.) 

But since Sebastian liked the S & C's Rabbit,   I agree with LDG -- why not contact them about the possibility of small amounts of other proteins.      you obviously have to feed him something he will eat!  

Patches took them both when he was sick.  It also has an anti-inflammatory effect along with being an antibiotic.  I think for IBD the antibiotic is kind of a safeguard thing.  When the digestive system isn't working right bad bacteria can overpopulate.  The way she explained it to me the anatomy of the cat makes it very easy for an overpopulation of bad bacteria to move into the liver.

I think Flagyl has become the automatic medication for digestive problems with cats.  The vets that I took him to before the one he goes to now always gave him Flagyl even though they didn't really have a clue what was going on with him.

Chumley, as it turned out, didn't have IBD. We don't know what it was in terms of Western Medicine, but he had an energy imbalance and a GI bacterial imbalance that (without biopsy) our traditional vets were calling IBD. This was corrected with Chinese Meds and Probiotics. We used slippery elm bark powder and George's aloe vera juice to reduce his GI inflammation.

He was given 4 or 5 courses of treatment with Flagyl. It did nothing for him. I personally am not a believer in using antibiotics without knowledge of an infection or bacterial overgrowth. ...and based on Chumley's experience and the rescue kittens this summer, I've become a believer in the use of probiotics for bacterial overgrowth. Of course, if it's known there is an infection, I would suggest the use of antibiotics and THEN probiotics.

...and hopefully the issue of long term use of pred (ETA: or any steroid) with Sebastian won't be a problem. he'll need them only short term. :cross:

maewkaew said:

 
  Re diet:  What about  Nature's Variety ,  at least the canned.   I think  that would be lower carb.    My cat's internist (a DACVIM)  recommended the canned NVI  in a novel protein as something that would be lower carb than the "prescription" food.   

 I think their rabbit may be from China  but they also have venison or lamb.    The rabbit and the venison have pork liver.  but maybe that is novel to him too?   The lamb has only lamb . 

Louis ate the venison and did very well on it.    ( and i saw what happened when he got into some other food with beef  and had bloody vomit and diarrhea which he never had on the NVI venison)    

 Unfortunately,  their dry foods all have chicken meal included except the Limited Ingredient ,  but that's got turkey.    

 ( Louis was already diabetic  which is why the vet was more concerned about the carbs with him.) 

But since Sebastian liked the S & C's Rabbit,   I agree with LDG -- why not contact them about the possibility of small amounts of other proteins.      you obviously have to feed him something he will eat!  

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Well, it seems at this point that he has only had one confirmed bout of pancreatitis back in July. I will keep budesonide on the table as an option. The doc did reluctantly (because it doesn't work as well for this condition) offer the steroid injection Depo Medrol (sp?) to reduce the stress of pilling, but I heard some bad things about it and refused it. I figured if he has a bad reaction to it, then I'm screwed. At least with the pred, it can be stopped. Are blood glucose checks only done at the vet through blood work? Can they be done at home?

Thanks for the food suggestions. Previously, I did try all flavors of the Nature's Variety canned and he didn't like any of them. I guess if he's desparate for something different from the Rx foods, he might reconsider. I wish NV carried rabbit in their canned LID line. For now, I'm going to be careful about how many foods I'm giving him. I can introduce other novel foods slowly as he [hopefully] improves.

Denice said:

 
Patches took them both when he was sick.  It also has an anti-inflammatory effect along with being an antibiotic.  I think for IBD the antibiotic is kind of a safeguard thing.  When the digestive system isn't working right bad bacteria can overpopulate.  The way she explained it to me the anatomy of the cat makes it very easy for an overpopulation of bad bacteria to move into the liver.

I think Flagyl has become the automatic medication for digestive problems with cats.  The vets that I took him to before the one he goes to now always gave him Flagyl even though they didn't really have a clue what was going on with him.

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Oh, okay. That makes me feel better. It does seem like Flagyl is one of the safer antibiotics, relatively speaking.

LDG said:

Chumley, as it turned out, didn't have IBD. We don't know what it was in terms of Western Medicine, but he had an energy imbalance and a GI bacterial imbalance that (without biopsy) our traditional vets were calling IBD. This was corrected with Chinese Meds and Probiotics. We used slippery elm bark powder and George's aloe vera juice to reduce his GI inflammation.

He was given 4 or 5 courses of treatment with Flagyl. It did nothing for him. I personally am not a believer in using antibiotics without knowledge of an infection or bacterial overgrowth. ...and based on Chumley's experience and the rescue kittens this summer, I've become a believer in the use of probiotics for bacterial overgrowth. Of course, if it's known there is an infection, I would suggest the use of antibiotics and THEN probiotics.

...and hopefully the issue of long term use of pred (ETA: or any steroid) with Sebastian won't be a problem.

he'll need them only short term.

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I do hope to incorporate some alternative treatments as soon as I work out a plan to not make it stressful. I hope to give him one gel cap that contains all his pills, followed by one syringe with all his supplements once a day.  Is this wishful thinking? 

Regarding your comment "without knowledge of an infection or bacterial overgrowth":  During the two rounds of overnight hospitalization (the one in July and the one just a week ago), his blood work showed elevated WBC both times, which can indicate infection, inflammation or cancer. I believe he had blood work done in between the two "flares," and was within normal range. I'll have to double check this when I go home. Perhaps vets like to offer Flagyl to take care of the infection component...just in case. 

I don't recall what Chumley's symptoms were or what his labs looked like. Where his numbers off? Or was he just not eating? If you want to direct me to the thread about Chumley, that is fine, too. I'll read it.

Thanks...I hope it is only short-term, too.

GoHolistic said:

 
  Are blood glucose checks only done at the vet through blood work? Can they be done at home?

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 Yes they sure can be done at home,  using the same glucometers that human diabetics use.  for example the Reli-On from Walmart has very good reviews.    There's a lot of tips, videos etc. online about home blood glucose testing for cats.    In fact it's more likely to be accurate at home because it's less affected by stress. 

I'm not saying to test all the time like  you would if he were known to be diabetic.    but if he ends up being on a steroid for over a month I would start testing maybe every other week or at least monthly.Normal BG for healthy non diabetic cats is usually about 60-100 mg/ dL.       Or you could start out getting a base line  so you know what is sort of normal for him.    

Hopefully he won't be on it long term anyway! 

As far as blood glucose testing, I used a human one from Walmart (Relion). What some people did from www.felinediabetes.com was bring their human glucometer from home and when the vet tested for glucose, use their meter too and compare numbers. That site also has helpful info on how to do home testing.

GoHolistic said:

I don't recall what Chumley's symptoms were or what his labs looked like. Where his numbers off? Or was he just not eating? If you want to direct me to the thread about Chumley, that is fine, too. I'll read it.

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No, you wouldn't be familiar with Chum's story, that was back in 2010. His labs were normal. His symptom was horrible, chronic diarrhea. Reading his story wouldn't be of any help to you in this situation.

I didn't mean to give a "dig" about alternative treatments. My only point was that vets do seem to throw metro (flagyl) at GI issues "just in case." In fact, vets seem to like to throw antibiotics at a lot of issues "just in case." I no longer take their advice on this. When Shel had two teeth removed due to FORLs, they wanted him on antibiotics. I told them that if he develops an infection, we'll use them. (He didn't develop an infection). When Chumley had the canine removed, we did use the antibiotics "just in case," because of higher potential for development of a problem.

Obviously if there's an elevated WBC, there's reason to suspect an infection. :rub:

I'll look into the at-home glucose checks. I guess that means I'd have to prick him???

No worries, LDG. You know me...if there's an alternative treatment that works, I'm all in! Btw, my receipt doesn't say that they gave Sebastian the Flagyl, so maybe the doc changed her mind.

Sebastian did well tonight, but I guess that can be expected with the pred. His spirits were up, he ate well, and even played with the shadow puppet that I make on the wall.     It took a little bit of stubbornness on my part, but I didn't give in, and he finally ate 1/4 can of the RC Rx Rabbit wet food. I'm sure the pred and the what's left in his system of the Mirtazapine had a lot to do with this. I highly doubt he would've eaten it without any "assistance."  I'll have to see what I can do about the consistency. It's kind of dry. Even after adding almost 1 tablespoon of water, it was wetter, but he'd lick up the juice and leave the meat all smashed down at the bottom of his bowl. It took him like 1.5 hours to finally finish it with me having to fluff it every 10 minutes. I might have to try putting it into a blender. He also ate 1 tbsp + 1 tsp of dry very heartily.

So then came the time when I needed to give him the 1/2 pill of pred (2.5 mg) to make the 7.5 mg total for the day. I was dreading it. I scoured all my cabinets thinking, "I've got to have a small gel cap somewhere."     And there it was...I had a foil packet of Proviable DC for Cats (its a probiotic) that comes in small gel caps. I even compared it with my gel cap chart, and it was a size 3.    Unfortunately, everybody was already fed, so I had to waste the contents of the gel cap (tomorrow I'll just give it to Boo). I was able to comfortably fit 1/4 tab of Pepcid and the 1/2 tab of Pred with plenty of room to spare. I coated it with a thin layer of butter and had a syringe with water ready in case he needed help getting it down. It was a breeze! It went right down! This is going to be so much better for the both of us! I do think I could probably go a little smaller on the gel cap...say a size 4, but they are harder to find.

For now, he ate...he seems comfortable...and that means I can get a good night sleep. 

Sebastian continues to eat on his own. He's exhibiting all the classic side effects of prednisolone - ravenous appetite, and more drinking and urinating than usual.

I'm grateful that he his eating on his own and that he's eating the rabbit diet without an issue. But I am also a little bothered by it. How do I know if the pred is working for the inflammation/IBD and actually making him better? I fear that the pred makes me think he is getting better, but that it's all just a side effect of the pred.  Also, he seems to be completely consumed by the ravenous appetite. He won't relax or do some of the things he usually does because, instead, he is following me around the house crying and crying for more food. Will these symptoms subside as his body gets used to the pred? Or do they only go away once pred is reduced or stopped?

Also, Sebastian has developed pudding-like diarrhea. I suppose this is either from the pred, the new diet, or both. So, I have started him back up on the probiotics in the hopes that they'll help firm things up.

I was doing some more research and had to reference Sebastian's labs. For the past two months or so, he's consistently had a high neutrophil count, although it varied in severity. Apparently there is something called Neutrophilic IBD that is more rare. Neutrophilic IBD is when inflammation is actually caused by intestinal bacterial overgrowth (IBO). If this is what Sebastian has, then the pred is not getting to the route of the problem. The more common cases of IBD show increased levels of lymphocytes. His lymphocytes and eosinophils have always been within normal range.

I don't know about the initial side effects of prednisolone because Patches had hepatic lipodosis when he started it.  Nothing will make a cat with fatty liver eat.  He started eating again 3 weeks after he started on the steroid and his appetite was the same as it had been before when he wasn't sick.

That's really interesting about the Neutrophilic IBD. If that's the case, you may want to consider taking advantage of his appetite on the pred, and get some S. Boulardii into him. It's a horrible tasting probiotic, but it has been indicated as helping with IBD (in people studies). But you can't sprinkle it on food, it's too bitter. It's not a typical probiotic, in that it doesn't recolonize the gut. It has to be given every 12 hours. It's yeast-based, actually a close relative to Brewer's yeast. This is a pretty good review piece - not so much as re: IBD, but the section on its anti-inflammatory effect: http://www.horizonpress.com/cimb/v/v11/47.pdf

My understanding is that S. Boulardii and L. acidiophilus work really well together. Right now, I actually use 2 probiotics for my cats. One is Nexabiotic 20-strain, which has the same does of S. Boulardii as the Jarrow formula (5 billion CFU in one capsule) - but unlike the Jarrow (which we used for the kittens that had coccidia in June), my cats WILL eat the Nexabiotic sprinkled on to their food. The dose is 1/2 a capsule 2x a day. I also give them Natural Factors acidophilus+bifidus (5 billion CFU), 1/2 a capsule am and pm with the Nexabiotic.

Carolina did find a study where a cat was given S. boulardii to treat C. diff - that's where we got the dosage.

Thanks guys. What's even more interesting is that there is such thing as neutrophilic cholangitis, which is caused by an infiltration of large numbers of neutrophils into portal areas of the liver and into the bile ducts, and can also affect the pancreatic duct. Both bile and pancreatic fluid enter the intestine from the same location. You'd be proud of me for looking at how everything is connected to make a "whole" rather than one individual aspect.    The word "suppurative" is used interchangeably with "neutrophilic" so I've been conducting searches on both.

Neutrophilic cholangitis is thought to arise following ascending infection from the gastrointestinal tract. Hence, it may be more frequently associated with pancreatitis.

http://www.ivis.org/journals/vetfocus/19_2/en/5.pdf

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Of course, all of the resources I am coming across want to treat the bacteria with an extended course of antibiotics. I will opt to start with the probiotics with the additional strains, including S. Boulardii. By the way, here's another resource that was interesting. It's for human and animal models, but they talk about probiotics towards the end: Importance of Bacteria as Trigger in Inflammatory Bowel Disease

And a final note for tonight...I plan to bring up the thought of Neutrophilic IBD to the doc when I talk to her this week, but if she dismisses it as nonsense, I may need to go see another vet. They've been great and are very knowledgeable, but the last visit we had she told me that one of their sayings is to "treat the symptoms." Well, that's great and all, but I'd like to figure out what the problem is and address it BEFORE there are symptoms to treat. I'd like to prevent further pain and physical stress on my cat if I can. They don't seem to look ahead to how we can manage something. They only know "right now." And some things I've brought up we kind of disagreed on, like using prednisone vs. prednisolone. She said studies show there's not much of a difference in one over the other anymore. She did give me the prednisolone, but I wonder if I hadn't said anything. When I told her I fed Sebastian some of the S&C freeze dried raw, her response was, "It wasn't the actual frozen raw was it?" So, I think they're one of those places that's against raw. The holistic vet that I posted about previously does support raw.

That anatomy of the cat is why vets give the flagyl so freely with gastro problems even if they don't know what the problem is. 

Most conventional vets are against feeding raw because of bacteria.  My vet, even though she doesn't really push it, does prefer wet over canned.  A lot of vets think there is no difference and a few actually prefer dry over wet.

Denice said:

 
That anatomy of the cat is why vets give the flagyl so freely with gastro problems even if they don't know what the problem is. 

Most conventional vets are against feeding raw because of bacteria.  My vet, even though she doesn't really push it, does prefer wet over canned.  A lot of vets think there is no difference and a few actually prefer dry over wet.

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So if Sebastian was your cat, would you give him another round of Flagyl? I'm just looking for your opinion. I value what you guys have to say. 

Right now I'm not going to pursue raw, especially if there's the possibility of Sebastian having an overgrowth of bacteria.

Me personally? Yes. From what I've read the treatment is Flagyl, amoxicillin, and prednisilone. I would also consider a cooked diet, but it's more important that he eat period.