transitioning from lactulose to miralax (restoralax) dosage

My 16-year-old cat has severe constipation issues, most likely due to an unoperable tumour near her liver that is slowly pushing her organs out of place. Pretty sure from x-rays and vet examinations that it is not mega-colon. Other than the constipation, she's still fine. She's on cipriside 2 time daily, lactulose (0.8-1 ml 3 times daily), Sub q fluids when needed; and had an enema about 2 weeks ago (posted in the enema thread). The enema experience totally exhausted her. The constipation is coming back. Also exhausting for her. I'm giving up on the messy, ineffective lactulose and trying miralax (restoralax). I've read the various posts about how to mix with water and syringe use. Thank you for this information.

Question #1: this old duchess is tiny - 5.2 pounds. Is 1/4 tsp of miralax too much? I don't want to over do it, but I'm worried that starting small and working up will put us in another enema situation. For her, an enema is a terrifying trip to the vet, an indecent act, and at least 24 hours without any decent sleep. For me, it's 24 hours without any decent sleep, lots of cleaning, and tons of laundry.

Question #2: can I go straight from the lactulose to miralax -- i.e. give her the third dose of the day lactulose tonight, then start 2x daily miralax in the morning?

Thank you in advance for any advice and thoughts on this matter.

In a side note on miralax: not one of the 3 vets has mentioned miralax which can be bought otc . wondering if they don't mention it because they lose their prescription fee and medication mark-up..

Hi again cocheezie !

I'm sorry to hear about that possible diagnosis.

First of all, you can simply switch over to the RestoraLAX immediately...whenever she's due for her next Lactulose dose. On top of that, because the Lactulose hasn't been effective, I'd be tempted to just start the RestoraLAX stat.

How much? It "works" dose-to-effect.....so, you could start with 1/4 tsp (perhaps even twice a day, because her constipation seems chronic) and then adjust according to the resulting stool...too loose, reduce the dose; too hard, increase.

Are you feeding any dry food (I can't remember) - but, if so, my advice would be to ditch it. I'd also be tempted to add in a probiotic. Here's a post by another Canadian member with brand names:  http://www.thecatsite.com/t/245881/pro-biotics#post_3221134

About the Vets not mentioning RestoraLAX? It might well be that they're not even 'in the know'....I've introduced its use to several experienced Vets - none of whom were aware of it! Next time you're speaking with your docs, you should ask. If they're doubtful, tell them to ask or search on VIN - The Veterinary Info Network, a discussion forum for Vets and Techs: http://www.vin.com/

There's another benefit of MiraLAX over Lactulose. Lactulose has a high calcium content and, especially with older cats, one shouldn't mess with their calcium balance.

So far as profit margins and the bottom line goes....that's better left for you to assess. (tho I'm of like mind, I suspect!)

Hope that helps!

That helps tremendously. Thank you. Starting immediately.

We've got her off dry food except for 4 bits of dry food twice a day. She's a master at hanging onto a pill so we give her 4 bits of dry food on a plate after the cisipride. This way, we know where she is going to try and spit it out.

Thanks again.

Miralax has been extremely helpful for my chronically constipated cat. The advice I always give people who are starting their cats on it is to be sure the cat is getting plenty of water. I put the Miralax in the food dish, add 2-3 Tbsp. of water and stir to dissolve. Then canned food on top, and stir again till the food is soupy. She doesn't even notice the meds are in the food and slurps it right up! Miralax is supposed to be odorless and tasteless, but when I have taken it, I thought it was pretty funky. The canned food covers the taste, plus it has the bonus of a high water content.

About two or three weeks after we started Bob on Miralax, she got very weak and lethargic, plus she lost weight very quickly. It kind of snuck up on us. When I took a really good look at her and her symptoms, it was obvious she was severely, dangerously dehydrated. It happened so fast and I cannot believe I missed the warning signs

I think it happened because Miralax works by moving water to the colon to help soften the stool. All her hydration must have gone to her colon and then out. She is fine now, and gets the Miralax every other day, but the experience was very scary (and easily prevented). Adding that little bit of extra water to her food has worked wonderfully, and even when she is not getting dosed, the water goes into her food.

The dosing is done by trial and error at first. Some cats get dosed twice a day and others only need it a few times a week. Bob is only 6 1/2 lbs. and she gets 1/2- 3/4 tsp, so your cat should be just fine starting out on 1/4 tsp. If she doesn't go after 24 hours pass, I would try upping it to 1/2 tsp. or doing two 1/4 tsp doses a day. It takes Bob between 12-24 hours to process the Miralax, but all cats are different. Like White Shadow said, you just have to watch, evaluate the stool and make small adjustments until you figure out what works best. Some folks find it helpful to keep a journal of times, dose amounts, conditions (straining, etc) and stool consistency to help hone in on the proper dosing schedule. I guess you could call it a poop log Good luck and I hope the Miralax works well for your kitty!

Thanks. I do add water to her wet food and we check her often for dehydration; and have a Sub Q bag always at the ready. I don't want to miralax in her food because she has always had a policy of always leaving something on her plate. Even if I just put a small amount out, I would never know if she got a full dose or not. We also have a diabetic cat who is determined, at any cost, to get at her food. Somehow, he even manages to get through closed doors. (This determination, by the way, has been helping tremendously in the strengthening of his hind legs. The higher up we put her food, the higher up he tries and eventually manages to jump.)

Last night, I gave her 1/4 tsp dissolved in 1 ml of water. So much easier than lactulose!. She did (after much straining) pass a small stool early this afternoon. She then hopped up on the bed and threw up twice. My partner cleaned and disposed of it and has been very vague answering my questions about the vomit so I am unable to tell how much she threw up. There was food involved. Her morning dose of mirilax was given at 11 a.m., followed shortly after by a small 2nd breakfast, and am hoping that she didn't throw up the miralax.

Life would be much easier if pet meds came with some sort of natural, non-harmiful dye so owners could tell if the medicine stayed down or came back up again.

Thanks again for all your help.

Again tonight, vomiting about 2 hours after giving 1/4 tsp miralax and 3 hours after giving cisipride. Is the problem giving the dose too soon after the administration of cisipride? Is there a certain order in which these 2 medications should be given?

I'll start with the last question......there wouldn't appear to be any particular prescribed "order" of administration, because there's really no interaction between the two drugs that I'm aware of.

Now, she has been vomiting all along - your very first post described that - and, I suspect (correct me if I'm wrong !) she was vomiting before she started taking the Cisapride.

So, based on that, I'd say neither of these drugs is causing it (even though, as you'll see below, vomiting is a known possible side effect of Cisapride).

My gut feeling is that she most certainly 'suffers' from stomach acid. That's extremely common with cats experiencing appetite loss/gastric issues. And, stomach acid is understood to cause vomiting.

There's a remedy for stomach acid that also appears to aid in intestinal motility - and, you're already using the Cisapride to 'encourage' her intestines to 'move things along'.

I'd be very tempted to try it (said with the usual disclaimer of "after speaking with your Vet").

First, some reading about stomach acid and treatments:

• http://www.felinecrf.org/nausea_vomiting_stomach_acid.htm#causes   Start at the page centre, "Toxins, Including Excess Stomach Acid" and read + skim through the symptoms. For the most part, ignore the references to CKD/kidney disease, because many of the gastric symptoms/issues are simply inherently "cat"
• now, move on to treatments here: http://www.felinecrf.org/nausea_vomiting_stomach_acid.htm#treatments   The author has divided these into three groups/classes/types - one option in the second group is Ranitidine (Zantac-75). Click that and pay particular attention to the second paragraph there, suggesting that Ranitidine may also help with constipation. There's a link there, but here is the reference from that link that makes the choice of using Ranitidine particularly interesting:

   _...cisapride stimulates feline colonic smooth muscle contraction......Our laboratory has shown that ranitidine and nizatidine,...stimulate feline colonic smooth muscle contraction in vitro...
  
  http://www.vin.com/VINDBPub/SearchPB/Proceedings/PR05000/PR00118.htm   (2nd last paragraph)

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  You're using Cisapride already to promote motility...Ranitidine, while primarily an acid blocker, also appears to promote motility.....therefore, if one were going to suggest an acid blocker for your cat, Ranitidine would seem to be the drug of choice.  That said, if it were me, I'd want to have my Vet  (at least) evaluate its use vis-a-vis already having one motility agent on board. (The author of that paper, btw, comes with some hefty credentials: http://www.cvm.umn.edu/vcs/sections/intmed/robertwashabau/home.html)
• The quoted reference there comes from a paper presented in 2001...there's a cat clinic in Australia that now uses Ranitidine to promote motility in constipated cats, and also uses the two other obscure drugs mentioned in the paper, prucalopride and tegaserod......here's the link to their site (1/2 way down, under "Medical Therapy): http://www.thecatclinic.com.au/info-for-vets/constipation-colectomy-and-perineal-hernia/

Now, back to the vomiting. From Plumb's Veterinary Drug Handbook, 7th edition:

 CISAPRIDE

Prescriber Highlights

• Adverse effects appear to be minimnal in veterinary patients; vomiting...can occur

Adverse Effects

.....occasionally vomiting...may be noted

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So, Cisapride itself might be a current factor in her vomiting (although, as we know, she's been long vomiting).

This has been long and perhaps complicated. You'll need to have your Vet 'on board' to see this through properly - it might be easiest, especially with all the references to have him/her read through this post - whatever it takes to settle her down and be nourished - then, the focus can be on helping her deal with whatever turns out to be the cause of all this.

Thanks for all the information and the links. There is the possibility, due to the tumour, that stomach acid is an issue. I shall certainly give them a read and print off copies for the vet. As her remaining time with us is limited, I'm sure we'll be seeing the vet quite often.

In the good news department, the switch from lactulose to miralax has produced 2 somewhat easier and fuller bowel movements in 2 1/2 days. She is much more comfortable, which is all we can expect and hope for.

I had a couple of afterthoughts for you - and these will tie in with keeping her comfortable.

The second link I gave you - Tanya's "Treatments" section - in the third category there, you'll find anti-nausea treatments. THAT is something I'd also be discussing with my Vet.

The second was about adding in a probiotic, to ensure that, on the front end of the digestive system, things are 'up to par'. That's something you can just go ahead and do. I think I already gave you a link to some Canadian choices in that regard.

Keep us posted!

(you know, you haven't yet properly introduced this girl !) (nor have we seen her )

Probiotics next on the list. Thank you. Think I have some zantac in the cupboard. I'll have to check the dose I have. I'd really only have to use it during a severe constipation/vomit cycle. She's doing really well on the miralax. Caught her having a bit of a wash today. Recently, she's only been washing what's absolutely necessary.

Photo will eventually be uploaded. My camera doesn't like her for some reason and never takes a worthy picturer. And must also look through my files for photo of very photogenic diabetic cat.

()

Remember, Zantac is really bitter, so it usually causes distress and profuse drooling. So, tablets, once the dosage is established, need to either be put into gelcaps or otherwise coated to cover the taste. Gelcaps might be available through a local pharmacy/compounding pharmacy, otherwise this will help: http://www.felinecrf.org/medicating_your_cat.htm#gelcaps   There is also an injectible form which can either be injected directly or given with the sub-q fluids - all that is found at the Ranitidine link in post #7

So far as when to use it, I'd say if she's averted from food at all, that might be a early sign of acid and time to intervene.

Sheeeesh !  I thought, at the very least we'd get a name by now!   .....so, OK, is she "Cocheeze" - or, "Cheezie"?

We'll do the name first:
Cochise = Co-chise (rhymes with piece). Previous owner thought that if she named the cat after an Apache warrior princess, her non-cat husband, who was interested in Native American history, might like the cat more - didn't work. When the previous owner died, even though arrangements had always been in place for us to take the cat, he thought the cat should be put down. This was the name she came to us with almost 5 years ago now. Mostly we call her Cocheezie but refer to her as "The Duchess" behind her back.

I have a wonderful local pharmacist. Don't think there will be a problem. Thanks once again.

Question: can miralax and slippery elm bark be used at the same time? SEL seems to be used for stomach acid, constipation, and diarrhea - like pumpkin?

Cocheezie went on a hunger strike this weekend, protesting the constant day-after-day prescribed vet wet food (don't blame her). We've switched back to soupy Fancy Feast pate with probiotics sprinkles and have had to start her on Sub-Q fluids again. She's eating and drinking but not enough to make much difference in hydration levels or weight. Because she's on a laxative, we need to keep her hydration levels high. It could be that she is getting closer to the bridge (tumour), but because she's eating and drinking, and otherwise acting normal, I think it was a protest. It could also be stomach acid but she hasn't been throwing up lately. I'm thinking about making up a SEL syrup to see if it helps. I don't want to take her off the miralax (1/4 tsp 2x daily) because it's working so well. I'd also really like to simplify things because between giving her the cisipride, miralax, sub-q fluids, and taking over some of the grooming, I'm not in her good books. She is a "if it's not my idea, it's not going to happen" cat. Any thoughts? It's hard being the good/bad guy.

cocheezie said:

 
Question: can miralax and slippery elm bark be used at the same time?

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Yes !

SEL seems to be used for stomach acid, constipation, and diarrhea - like pumpkin?

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Mostly yes there....on stomach acid, SEB isn't an antacid per se (as IS Pepcid AC) but, because it is a slimy, sticky liquidy substance, it coats/covers anything it contacts with a coating that reduces the acid's irritation. It isn't a stool softener but, again, because it is "slimy", it assists/facilitates the movement of fecal matter in the intestine. Its similarity to pumpkin lies in the fact that it's a soluble fiber - one that feeds the gut's bacteria, like pumpkin.

I'd encourage you to continue with the Pepcid, though, if there's any chance of acid.

 I'm thinking about making up a SEB syrup to see if it helps...

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If you're going to give the syrup with a syringe, be super-careful that she doesn't choke on it (breathe it in, which could cause a fatal pneumonia) - just a few drops at a time into the side pocket of her mouth, let her swallow and repeat. Some cats tolerate the syrup on a small amount of some irresistible food (like FF).

I usually manage to cover my bad tracks (from some of the pilling/medicating/etc) by immediately following them with some delicious treat/pampering. I recently had to instil an irritating eyedrop for two weeks...well, by preceding that with a shake of the Temptations bag and offering three of the bag's contents immediately thereafter, I then had a cat who came running for his nasty eyedrops !  With tablets, I have a couple of tiny syringes of tuna water at hand....my routine is a taste of the tuna water pre-pill, the pill, a water chaser, then the balance of the tuna water. "Pilling" is now a breeze once they recognize the pleasant pattern.

Thanks for the advice. I'll try a bit of the SEL powder and then the tincture in her food first. If it works, it's better than syringing her repeatedly - once with miralax, once with SEL. She won't touch the food that the miralax powder has been mixed in. And I'll let my partner bring in the food. Right now, she's accepting food more readily if my partner gives it to her than she does from me. Don't mind being the bad guy if that's what it takes. Everything has always had to be on her own terms or not at all. She has never been what one would consider a cooperative cat - no 'here, kitty, kitty.' She still favours sleeping on top of me at night when I'm not forcing anything on her. I'll settle for that.

Treats, pampering, petting, or rubbing the base of her tail no longer work. She's always refused human food - even tuna. We offered all sorts of human food over the last 4 years and sometimes mixed it in with what she considers food. No go. She throws up her nose at pill pockets. The animal shelter, however, was grateful for all the various barely opened bags of pill pockets.

cocheezie said:

 
Thanks for the advice. I'll try a bit of the SEL powder and then the tincture in her food first. If it works, it's better than syringing her repeatedly - once with miralax, once with SEL. She won't touch the food that the miralax powder has been mixed in. And I'll let my partner bring in the food. Right now, she's accepting food more readily if my partner gives it to her than she does from me. Don't mind being the bad guy if that's what it takes. Everything has always had to be on her own terms or not at all. She has never been what one would consider a cooperative cat - no 'here, kitty, kitty.' She still favours sleeping on top of me at night when I'm not forcing anything on her. I'll settle for that.

Treats, pampering, petting, or rubbing the base of her tail no longer work. She's always refused human food - even tuna. We offered all sorts of human food over the last 4 years and sometimes mixed it in with what she considers food. No go. She throws up her nose at pill pockets. The animal shelter, however, was grateful for all the various barely opened bags of pill pockets.

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I have been using SEB since late last year and have had some fantastic results with it - in fact I should do an update soon. If your kitty has issues with stomach acid or IBS, SEB can help with this as well, as it works to coat and soothe the intestinal tract.

I have not had to use a syringe to give SEB but rather put the mixture right into wet food. You might want to do this as well rather than using the syringe, so much easier (and safer) than having to deal with an uncooperative kitty 

All the best of luck with the SEB .. I hope your kitty can have the same great results.

PS: Once you start using SEB regularly, you may not need to give Miralax. I used to use Lactulose on occasion when Max (pictured) first started having problems with constipation, and it worked with good results. But I can't remember the last time I needed to use this.

Another question: does giving both SEL and mirilax cause thirst?

I put SEL in her food yesterday, and she ate - no problem. This morning she ate some of the SEL-laced food. I haven't had to give Sub-Q fluids for two days now. She's drinking a lot more water than she usually does. Too sudden to be diabetes, I think. She's not showing the same symptoms that our diabetic cat showed. The drinking could be SEL/mirilax related? or could be the beginning of kidney failure? Breath is a little smelly, but not acetone-y. She's doing only minimal grooming.

The vets have said her tumour was pushing her organs around. Her stomach, for example, was not actually where it was supposed to be. Because of this inoperable tumour, our thinking all along has been "as long as she's comfortable and having good days." She's been complaining about the SEL laced food for the last hour, and moving around. She doesn't seem to be in any discomfort. I groomed, and poked and prodded. Got one growl when I was near a place where I worked on a hair mat yesterday, but that was a warning growl.

It could be the beginning of the downward spiral. We are monitoring and assessing and re-assessing on a daily, sometimes hourly basis. We think "okay, this is it" then she perks up and is good for a day or so or even longer. I'm leaving the SEL-laced food our for another hour or two, then I'll have to give her unadulterated FF. She's never regained the weight lost while sorting out the constipation problem, and because of the tumour she'll probably never gain the weight back.

cocheezie said:

 
Another question: does giving both SEL and mirilax cause thirst?

The drinking could be SEL/mirilax related? or could be the beginning of kidney failure?
It could be the beginning of the downward spiral. We are monitoring and assessing and re-assessing on a daily, sometimes hourly basis. We think "okay, this is it" then she perks up and is good for a day or so or even longer.

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Well, insofar as the SEB powder will absorb water, and the MiraLAX draws water into the intestine and stool, her system will seek water to compensate and so, she'll likely drink. I wouldn't go looking for other causes at this point, especially kidney failure. If your thinking about that comes from human medicine (organs shutting down, etc), I would really close the door on that.

About the increased drinking (which I think is a good thing), I've heard/read about cats allegedly not having a "thirst drive" because they evolved in desert environments and received their hydration from their food...but, I've seen cats (mine) who grew up with available water sources and fed dry foods drinking liberally.....then, when transitioned to an all wet food diet, never drinking at all. I feed/house/pamper a neighbourhood stray/freeloader? who, when fed wet foods doesn't touch the water bowl....when it's dry food only, I have to fill up that oasis daily. So, it's my conviction that cats, like any other "land" mammal will avail of any water supply when it's required.

I think that the balance of her life is likely to be that continuing roller coaster. Deciding when to stop the ride is uniquely personal and is influenced by many factors. For me, I hope that I will be able to allow it to run its course pain free and then be able to read the inevitable message "I'm ready".

cocheezie said:

 
Another question: does giving both SEL and mirilax cause thirst?

I put SEL in her food yesterday, and she ate - no problem. This morning she ate some of the SEL-laced food. I haven't had to give Sub-Q fluids for two days now. She's drinking a lot more water than she usually does. Too sudden to be diabetes, I think. She's not showing the same symptoms that our diabetic cat showed. The drinking could be SEL/mirilax related? or could be the beginning of kidney failure? Breath is a little smelly, but not acetone-y. She's doing only minimal grooming.

The vets have said her tumour was pushing her organs around. Her stomach, for example, was not actually where it was supposed to be. Because of this inoperable tumour, our thinking all along has been "as long as she's comfortable and having good days." She's been complaining about the SEL laced food for the last hour, and moving around. She doesn't seem to be in any discomfort. I groomed, and poked and prodded. Got one growl when I was near a place where I worked on a hair mat yesterday, but that was a warning growl.

It could be the beginning of the downward spiral. We are monitoring and assessing and re-assessing on a daily, sometimes hourly basis. We think "okay, this is it" then she perks up and is good for a day or so or even longer. I'm leaving the SEL-laced food our for another hour or two, then I'll have to give her unadulterated FF. She's never regained the weight lost while sorting out the constipation problem, and because of the tumour she'll probably never gain the weight back.

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Hi there,

If you are doing both the Miralax and the SEB, then water consumption is even more important given the way both utilize water as White Shadow pointed out. SEB will absorb 10 times its weight in water, so it is important to mix the SEB with water before giving it. What I do is mix a capsule of SEB (which is a little less than a tsp of powder) with about 1-2 tbsp of water in a small dish and mix well. I then put 1-2 tsp of the mixture in wet food, and give this twice a day. You can certainly increase the amount of water in cocheezies wet food to ensure that she is getting enough.

What I have done with Max when he has been constipated at times, is to do a little light and gentle belly massage starting from the top of his belly and moving towards his back legs. This can help to free up any gas that might be trapped and have the effect of peristalsis in helping to move things along. You might try this with cocheezie if you feel she would tolerate this. At the very least, it might help to relax her. Hope this helps and that she is feeling much better soon.