Cisapride - regular vet vs. holistic vet

vball91

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Wow, what a great update. So happy to hear that Tim is continuing to do so well as you are weaning him off the cisapride.
 
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abbyntim

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Wow, what a great update. So happy to hear that Tim is continuing to do so well as you are weaning him off the cisapride.
Thank you!

In case anyone is interested, Tim is doing really, really well. We have completed two cycles of the yet-again reduced dose of cisapride with four days between doses. His last dose was Wednesday morning, May 14, and we'll dose again tomorrow morning; the last dose before that was Friday, May 9. Tim is on a roll and has set a new record for this weaning process: He's had a nice bowel movement every day for the past 15 days. They are very nice in terms of size and texture, plus he's passing hair in his stools. I couldn't be happier. We are continuing with the alternating tiny doses of psyllium and slippery elm, which are even smaller as I'm splitting the amounts between both cats, with Tim getting 2/3 of the dose and Abby getting 1/3. Both cats are doing well.

We will give Tim cisapride tomorrow morning and if he continues to do well, we will add yet another day between doses so he skips five days. If he continues well with a couple of cycles of that dose, then we'll stop. The holistic veterinarian is on board with this tentative plan. The schedule really is up to Tim.

I'll be taking Tim to the regular veterinarian in June for a cardiac ultrasound and chest x-ray. He was diagnosed with mild hypertrophic cardiomyopathy last year when he had his terrible constipation episode and I want to follow up on this. Additionally, when he had his terrible vomiting in February, they suspected mild asthma, so I want to follow up on that, too. I plan to print my spreadsheets to share with this veterinarian and add to Tim's file there. I am not sure how they will react to us weaning Tim off cisapride against their advice, but we had to try. In any event, Tim's doing very well right now and I have no reason to believe it won't continue, and that is what's important.

I am feeling very happy and proud of Tim and grateful for all of the advice and support I've received from those of you who have replied to my posts. I'm not leaving this site, but just wanted you all to know that I am so thankful and appreciative.
 

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Hey, good stuff
  Glad to read that you are doing supportive things like the SEB, psyllium. This will keep Tim in good stead as you continue with the transition.
 
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abbyntim

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Hey, good stuff
  Glad to read that you are doing supportive things like the SEB, psyllium. This will keep Tim in good stead as you continue with the transition.
Thanks! Yeah, I'm pretty happy. I prepared myself this weekend for the "lag" I was expecting to see after we reduced his dose earlier in the week. Similar to the "lag" that just about sent me over the edge at the end of April. Well, it never happened. Or hasn't happened yet. He's been pretty consistent between 23 and 26 hours since his dose reduction. Who knows, maybe he won't go tomorrow. But it won't matter. I do believe he's in charge now and it's just a matter of a few weeks, hopefully, before we're done with cisapride.
 
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abbyntim

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I love hearing good news!  
Thank you!

And through my detailed notes, I've realized Abby's hard stools only come around when we have "Santa Ana wind events" - it gets extremely hot and dry, among other things. The last two events, I added tiny, tiny, tiny amounts of fiber and increased the water in her food, and that made the difference; adding extra water alone did not help. After reading http://www.felineconstipation.org/gutbacteriaandfi.html several times and quizzing the holistic veterinarian about adding fiber, I suspected that I needed to support Abby's gut during these weather events so her stools could retain an adequate amount of moisture. Still fine-tuning her dose, but at least she was not constipated during the last event. :)
 
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abbyntim

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Another update on Tim's progress with cisapride weaning.

Tim continued to do very well on cisapride every five days (dose, four days between, dose). He was on a wonderful roll with a BM every day for 20 straight days. Most of them were around 23-26 hours apart, but he had a couple of 34-37 hour stretches. He had these longer stretches on daily cisapride, so we are confident it's nothing to worry about.

Yesterday morning, when he was scheduled to get cisapride, we decided to add another skip day and give him cisapride this morning instead. Of course, yesterday was the end of his 20-day run and I was a bit nervous going to bed last night, wondering when we'd see the next BM. Well, Tim did not disappoint: he went first thing this morning within minutes of consuming his first plate of food (he ate, then immediately went to the room with the litter boxes). As such, I know the cisapride he consumed with that food had nothing to do with his BM. His current schedule is dose, skip five days, dose.

If Tim continues to do well, we'll keep adding skip days until he's going a week between doses. At that point, we'll stop. Exact timing is up to Tim. From what I can tell about cisapride, it takes about a week to completely leave the body, though it is down to 1% approximately 67 hours after the dose. As we've increased the number of days between doses, Tim is spending more and more time with less than 1% of cisapride in his body; this morning when he had his BM, he was at 0.005%.

I am feeling more confident that Tim can poop on his own and the cisapride did not damage him. And I feel that by improving his digestion and maintaining these improvements in future, as well as keeping him well-hydrated, we can avoid constipation. To improve his digestion, he takes a daily probiotic. He get a tiny, tiny amount of slippery elm (less than 1/16 tsp mixed with lots of water) a few times a week. Finally, he gets a tiny, tiny amount of psyllium (less than 1/16 tsp mixed with A LOT of water) a few times a week on alternating days. Once Tim is off cisapride and is going regularly, I'll taper both fibers and see how he does. I do like that psyllium produces nice, hairy poops so I think I'll keep that on board as needed for hairballs. I also like that I've seen no signs of nausea since starting slippery elm, so will keep that on board as needed, as well.
 
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cocheezie

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Yay Tim!

fyi: Cocheezie went without a bowel movement for over 48 hours this week, then had a unstressful huge (i.e., lengthy) movement Saturday. I was getting worried that either her organs had scrunched some more, or that she wasn't getting the correct dosage miralax because I've taken to mixing it and her B-12 into a tidge of her favourite but forbidden food instead of giving it to her directly.

This a.m., my old girl had a throw-up in the early morning (food eaten through the night), and then threw up stomach acid mid-morning after an unstressful bowel movement. She had no interest in 1st breakfast so it was most likely due to stomach acid. My fault. I gave her the Pepcid AC and cisapride. She devoured 2nd breakfast and part of 1st breakfast. Because of reading that Pepcid AC (and Zantac) deplete B-12 because B-12 needs stomach acid for absorption, I've been cutting down the Pepcid AC to once a day. I haven't switched to something else for stomach acid because she doesn't mind being pilled with Pepcid AC and I'm sure she'd rather have her last days, medicine-wise, with the fewest miserable medication experiences possible. Yesterday, she was feeling so well that I decided to skip the Pepcid for the that day. I was trying to find a fine balance using as little Pepcid as possible. This morning, I did some further reading and found sites that state in humans, it's long-term use (over 2 years) of Pepcid that increases the risk of B-12 depletion (there's also a dosage related issue). With recommendations from the vet, I've already increased her B-12/iron/amino acid tincture, and for now, I'll stay with Pepcid 1x daily and see if once a day is enough.
 
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abbyntim

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@oneandahalfcats and @cocheezie, Tim says "thank you!" And I am almost giddy with excitement. Looking forward to the coming days and weeks to see how Tim does. Maybe he'll be done with cisapride by mid-June.

cocheezie, I am so sorry for what you are going through with your girl. Hope that Pepcid AC once a day works for her, along with the increased dose of her blend. Yes, you want her remaining time to be as comfortable and stress-free as possible.
 
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abbyntim

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We hit a rough spot this week, as Tim seems to be struggling just a bit with his newly-reduced cisapride dose. It is currently every six days (dose, skip five days, dose). He had cisapride yesterday morning (Saturday, May 31); his last dose before that was Sunday morning, May 25. As such, out of every 6 days, he spends approximately 3.5 days with less than 1% of cisapride in his system.

Since we started this new dose, out of nine days, Tim went three without a BM, but usually never exceeded 38 hours between BMs. This morning, he just concluded a 47.5-hour stretch without a BM. Needless to say, I didn't sleep too well last night. But I am trying very hard to remain calm and rational so as not to stress him. And I know this is a big step for him, spending more than half of his time with very little cisapride.

I mentioned, possibly on a different thread, that the litter boxes are in our home office, which is next to our bedroom. So I can usually hear Tim in the box (he is typically an early-morning guy, but will wait until he's had at least his first morning plate of food). His BM scratching is very different from when he just pees. And from what I can tell, based on the timing between his pre-BM scratching and his subsequent covering, he is not having any trouble getting it out. I just wonder if he feels the urge and is holding it, or if he's not really feeling the urge at times. And if he is feeling the urge but holding it, why? (we know he can hold it for days; he did so for over five days the last time we boarded him, and this was with daily cisapride and laxatone, plus super doses of laxatone from the vet on days 4, 5, and 6).

In any event, will be emailing the holistic veterinarian with my observations from the last week to get her input. She has instructed me to bring him in if he goes longer than 48 hours without a BM and I think she might like to know that he came pretty darn close this weekend.

To re-cap, Tim gets a probiotic each morning. Each evening, he gets either 1/16 tsp of psyllium or 1/16 tsp of slippery elm; both are mixed with plenty of water and added to his canned food. He's eating mostly Nature's Variety Instinct canned rabbit, but I had to mix in some other foods over the past week, which could have had an impact on his BM pattern, and which is why the holistic veterinarian wants us to keep his food fairly consistent until we're through the weaning process and Tim appears to be feeling good and pooping consistently on his own. See this post for the food issue that came up last week: http://www.thecatsite.com/t/272867/...tals-food-sensitivites-asthma/30#post_3568104.
 
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abbyntim

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Tim seems to be overcoming whatever caused him to go 48 hours between BMs. Each time he's gone, he's decreased the time by approximately 8 hours. So he went late Monday night, 40 hours later, and early this morning, 32 hours later. Dare I hope for tomorrow morning and approximately 24 hours? Once he gets in the box, he's not struggling at all and his BMs look nice.

So far, this is the exact same pattern he was on at the end of April when we reduced cisapride dosing frequency to three days between doses (or every four days) and I was freaking out. It was at the end of this pattern that he had a BM every day for 20 straight days, most around 24 hours and a few at 36 hours, even as we reduced frequency to four days between doses (or every five days). His current dose is every six days (five days between doses) and we will remain here until he stabilizes, hopefully one more dose on Friday. Then we'll decrease the frequency one more time and hopefully finish out the month at that dose, then see how he does. This is what the holistic veterinarian recommended in her email to me on Monday.

The holistic veterinarian thinks Tim is doing well. It's been a long process so far, already three months, but we're very close. Now it's up to Tim. She does want us to keep Tim on the small amount of psyllium each day and not alternate with slippery elm. Instead, use slippery elm in addition. Based on the size of Tim's stools, she's not concerned about bulking them a bit right now, as that will help stimulate him to go; this is the concern, not him getting it out. Once he's been off cisapride for several weeks, we'll work on tapering the psyllium. We are also to increase our playtime with him, as exercise stimulates motility and reduces stress in everyone. We noticed a major change when Tim started having daily probiotics and he's much more active and playful; it's fun to play with him and watch him play with Abby.

I am trying to keep Tim's food consistent. I located more cans of "original" rabbit on Sunday, so I have enough to feed Tim primarily rabbit through June. I am starting to very gradually add in some other foods, though, as I can see I will be forced to sooner rather than later. I was really hoping to keep his food consistent as we finish the weaning process, but it is what it is. I have a few more options for getting more rabbit, and I can always buy more three-ounce cans as I've seen plenty of those; they're just pricey and I didn't want to spend the money if I could avoid it. He is continuing with probiotics and psyllium every day, as well as slippery elm every other day, which I may increase as I begin to add more foods. So all in all, I'm very happy with his progress.
 
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abbyntim

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Feeling cautiously optimistic. Tim did not go at 24 hours yesterday morning, but pretty close. He went some time after I left for work, approximately 27-28 hours after his last poop (I really need a camera trap on the litter boxes so I can pinpoint time - ha). This morning he went early, which is pretty standard for him, about 21-22 hours after yesterday's.

Despite the daily doses of psyllium and several-times-per-week doses of slippery elm, his poops are really nice in terms of size and texture. I am hoping that we figured out the optimal amount for him. His poop size is pretty much the same as his pre-fiber poops, and much smaller than what he was pooping on Wellness grain-free canned and, in particular, dry, and they're a little bigger than Abby's. The holistic vet has told me that his poop size does not put him anywhere near being in danger of megacolon, which is a huge relief. And I learned a new term yesterday: "psyllium-poop", a shiny, glossy poop, which he definitely does not have, though the texture seems improved.

Regarding cisapride dosage, he had a capsule today. Provided he stays mostly on track, we'll shift to once per week, where we'll stay through the end of the month. If he seems to still be struggling, we'll stay at the current dose a bit longer. It's up to Tim.

What we're doing:
  • Keeping his food mostly consistent with Nature's Variety canned rabbit as the primary food. I rotate in small amounts of NVI LID turkey and Lotus Just Juicy turkey and pork varieties, so he gets rabbit plus one other on any given day.
  • Proviable DC in the morning, one capsule
  • Psyllium in the evening, 1/4 capsule, which is 1/16 tsp, mixed with a lot of water
  • Slippery elm several times a week, just shifted to morning, which is when we do the most food mixing; still adjusting dose, though I've never exceeded 1/16 tsp powder mixed with a lot of water
  • Cisapride every six days (dose, skip five days, dose), with the hope that we'll shift to weekly next week
  • Just added a small portion of a "calming treat" for the time being because the house next door that's been empty for almost a year just sold and they're working on it. Naturally, this is on the side of our house with our home office and litter boxes, and they're doing work between the houses.
 

cocheezie

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Well done. I'm assuming that when Tim is off the cisapride altogether and everything is working the way it should, that you are throwing a huge party and we are all invited. :)
 
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abbyntim

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Yes, I will so be celebrating! Although I think it will take a while before I feel comfortable doing so. At this point, the cispride is likely only helping the day after he gets it; all the other days, he's doing it on his own. We'll just have to see how he does without his weekly jump-start. I think if we go a month with fairly regular poops and without the jump-start, I will declare victory and have a celebration! :)
 

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Glad to read about Tim's continued progress, even with a few minor (in the grand scheme of things) setbacks. 
 
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abbyntim

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@GoHolistic, thank you!

At this point, I wonder if cisapride doses this spread out are even having much of an effect. I was expecting Tim to have a BM around 6:00am on Saturday because that was the day after his cisapride dose and that's when he usually goes the day after cisapride. But he didn't go until about 9:30, which is okay, but I just wonder. I've read that cisapride is most effective once it's built up in the system. Now that Tim's doses are so spread out, the amount in his system runs down to pretty much 0% for about two days before he gets his next dose, so no build-up. As such, I suspect he's doing most of this (pooping) on his own. Also, by reviewing my increasingly-detailed notes and spreadsheets, I am not seeing the same relationship between BM timing and cisapride that I saw when there were fewer days between doses. But we will continue the weekly doses through this month before stopping entirely, just in case they are giving him some sort of jump-start that we don't want to abruptly stop.

I would like to think that Tim is doing this all on his own and the cisapride is having no effect at this spread-out dose. Rather, that it's more of a placebo for me.
  But I guess we'll see for sure in July once he's no longer taking it at all. I will, of course, continue to update in case anyone is interested.

I would caution anyone considering weaning a cat off cisapride to do it with a veterinarian. Even though the vet who prescribed it said "no" to taking Tim off cisapride, I found another vet who was willing to work with us to try. But I could never have gotten this far without her guidance and without the support of everyone here. Truly, there were times I was ready to give up and resume regular cispride. I still have those thoughts on occasion. But we're so close and we need to see it though, to see if Tim can manage without cisapride.
 
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goholistic

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I would caution anyone considering weaning a cat off cisapride to do it with a veterinarian. Even though the vet who prescribed it said "no" to taking Tim off cisapride, I found another vet who was willing to work with us to try. But I could never have gotten this far without her guidance and without the support of everyone here. Truly, there were times I was ready to give up and resume regular cispride. I still have those thoughts on occasion. But we're so close and we need to see it though, to see if Tim can manage without cisapride.
Great advice! I've never had a cat on cisapride, but I've read that its something their bodies can become dependent on. When this is the case, an abrupt stop could really wreck havoc. Your approach was/is a great example of how it should be done. Hats off to you! 
 
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