Cisapride - regular vet vs. holistic vet

tdonline, I don't know a whole lot about cisapride. And I feel like a complete idiot as my cat was on 5mg every day for 9 months, then 5mg every other day for 1 month. Now we're trying 5mg with two days between doses, probably for most of April.

Cisapride helps move food quickly through the digestive tract. I just recently learned that a cat can become dependent on this, which is why I am weaning my cat off, rather than abruptly stopping. When our cat was originally prescribed cisapride, the vet said we could look into reducing the dose or perhaps taking him off in the future. Now this same vet is saying he needs to stay on it for life. A holistic vet that we recently started seeing believes we should try weaning the cat off cisapride. We drastically changed the cat's diet, transitioned him entirely to wet food, which is why the holistic vet, my husband, and I would like to see if we can get him off cisapride.

I've read some of your posts about your cats and the redirected aggression. I'm very sorry you are all dealing with this, and constipation is definitely a bad side effect. And you know how serious it is. Another member here, oneandahalfcats, successfully got her cat off cisapride after several months. So it seems cisapride can be used temporarily to keep thing moving along. But I would definitely discuss all angles with the vet and, when you're ready to stop, make sure you taper the dose.

Thanks Abby.  It's frustrating because many of the things that have worked for catsite members haven't for my girls.  I have tried SEB and it actually backs them up even more.  I've tried fish and coconut oil and Dory, who needs the most help, can't abide by either item.  My vet recommends miralax and petroleum jelly, followed by Colace and suppositories and finally, stimulant laxatives.  The latter works somewhat (I've given it twice in 4 months, it worked once and didn't another time) but I don't want to use it with any regularity.  I was able to use suppositories on Dory a handful of times and now she absolutely will not comply.

Ideally, I would like an aid that will get Dory and to lesser extent, Josie back on their pooping schedules (24-36 hours for Josie, 36-48 hours for Dory).  But that aid would be temporary and without side effects.  Obviously, I'm at a point where Cisapride may not be ideal but may be necessary.  I'll call the vet and discuss.

tdonline, I hope you are able to find a solution and I wish I could help. I've been relying on cisapride for so long that I feel I am now entering a new phase - how to manage my cat in case he backs up? He did really well on cisapride and I'm not aware that he had any side effects in the short term, but I don't want him on a medication that he will need to depend on for life, unless he truly needs it, and one that can have side effects. I haven't read all of your posts, but I'll throw out a couple of obvious questions: What are you feeding? After Tim's second severe constipation episode, especially when we were told by the vets that cleaned him out that his stools were like concrete, we realized he needed more hydration and transitioned him from mostly kibble to all canned. It sounds like fiber backs up your girls, so are you feeding a low fiber food? I've noticed that higher fiber makes Tim's stool larger (and presumably harder to pass), so I pick the larger veggie chunks out of his food, which keeps his stools smaller.

As a quick update on Tim (and Abby), both had pretty nice bowel movements last night. Quantity and texture were both good. Abby's was almost exactly 24 hours after her last one and, given what she produced, I am hopeful she is back to regular following the earthquake. Tim's was anywhere from 14-18 hours later, so a definite improvement from his two back-to-back 36-hour stretches. And the quantity and texture was good, too. I am hopeful that he is beginning to regulate after the earthquake and as his body adjusts to less cisapride.

I was selfishly hoping Tim would go again this morning and get back on his morning schedule. It's a lot easier for me to monitor. But, alas, nothing from either cat this morning. We'll see what happens - maybe Tim won't go tonight, but will get back on his morning schedule tomorrow.

As we continue with our next step in cisapride weaning, skipping two days between doses, I am excited to report that Tim has returned to his early morning schedule and he left nice deposits in the litter box at roughly the same time for the past three days. We will continue this dosage pattern for the next couple of weeks, exact time depending on Tim. Abby is also back on schedule. I am feeling hopeful!

Glad that decreasing cisapride is working for you.

AbbyNTim said:

 
As we continue with our next step in cisapride weaning, skipping two days between doses, I am excited to report that Tim has returned to his early morning schedule and he left nice deposits in the litter box at roughly the same time for the past three days. We will continue this dosage pattern for the next couple of weeks, exact time depending on Tim. Abby is also back on schedule. I am feeling hopeful!

Click to expand...

Hey, that's wonderful! It must be such a relief to feel like you are finally turning the corner after all that has gone on before.

Lots of positive vibes and best wishes for continued progress! ...

tdonline said:

 
Thanks Abby.  It's frustrating because many of the things that have worked for catsite members haven't for my girls.  I have tried SEB and it actually backs them up even more.  I've tried fish and coconut oil and Dory, who needs the most help, can't abide by either item.  My vet recommends miralax and petroleum jelly, followed by Colace and suppositories and finally, stimulant laxatives.  The latter works somewhat (I've given it twice in 4 months, it worked once and didn't another time) but I don't want to use it with any regularity.  I was able to use suppositories on Dory a handful of times and now she absolutely will not comply.

Ideally, I would like an aid that will get Dory and to lesser extent, Josie back on their pooping schedules (24-36 hours for Josie, 36-48 hours for Dory).  But that aid would be temporary and without side effects.  Obviously, I'm at a point where Cisapride may not be ideal but may be necessary.  I'll call the vet and discuss.

Click to expand...

Hi tdonline .. How are you and everybody doing?

I can certainly understand your wanting to find something that can improve Dory's situation and totally understand your concern that she may be developing megacolon. One question I would ask is, have her bowel movements increased in size from what you have noted when she goes? If not and the stools remain soft, then she may not be developing megacolon. Megacolon is the stretching of the colon to the point where nerve damage occurs from chronic constipation over time, OR from pelvic injury.

Cisapride is a motility drug that promotes the rapid transmission of waste through the intestinal tract, and in addition creates sensation in the colon to promote bowel movements. If megacolon has been diagnosed as the result of pelvic injury or chronic constipation over a period of time, then cisapride is usually a lifetime thing, or, surgery is performed to remove the colon. Cisapride may be something that can help, but unless you are dealing with a motility problem rather than a stool retention problem as the result of anxiety, I don't know how cisapride would be more effective than laxatives and suppositories? You could try this and see if it makes a difference, but if you don't see results within a month or so, I wouldn't keep Dory on this. 

Abby, my girls eat primarily canned food with kibble as treats and enticement with medication.  They usually do not eat more than 1 tablespoon of kibbles a day--2 tablespoons when they need extra wooing/placating.  I always add water to the canned food.  We compromise with 50% Fancy Feast and Friskies and 50% of grain-free Wellness with Merricks, Natural Balance and Sheba thrown in the mix.

The vet office called and said Dory should come in for a blood test.  I'm hesitant because Dory and Josie just reached two weeks non-separation...and I don't want to upset the dynamics by taking Dory to the vet.  If she gets stressed out and she has to be separated again...

Abby, I am heartened by Tim's progress.  It sounds like it is possible to use Cisapride, decrease and/or stop the dosage without constipation returning.

Hi One, Dory's BM are definitely bigger since she's holding onto them for 4-5 days as opposed to 1-2 days on her old schedule.  So, yeah, the concern is the size is stretching her colon.

I'm hoping a motility aid would make it more difficult for her to hold onto her poop.  So even if she's holding because of anxiety, she would have to go eventually.  I think that's what happens now but I want to decrease that time to a more reasonable 2-3 days and hope she slowly returns to schedule as we work even more slowly on her relationship with Josie (who is also constipated but to a lesser degree).

Thank you, everyone! Tim went again today right on schedule - four days in row now. He had cisapride yesterday, but only a few minutes before he used the litter box, so I don't think the cisparide had anything to do with yesterday's. So far, I am not seeing any significant difference with Tim's litter box habits and the varying amounts of cisapride in his system on a given day. We are cautiously optimistic that his constipation was due to lack of moisture in his diet and not a motility issue, though only time will tell. We've been on a reduced dose for one month now - 5mg every other day for most of March and now 5mg with two days in between for the past week. This is after 5mg daily for nine months.

tdonline, maybe you should try cisapride at this point, at least for a short time. Believe me, if nothing else works, I will put Tim back on as he has been very regular - mostly every 24 hours with a few 36 hour stretches between BMs. It's true there is risk of side effects and cisapride is not cheap. But if that's all that works, it's better than the alternative. I haven't explored other options, though, so that is where I'm at. It seems that cisapride is a drug of last resort, so maybe our vet shouldn't have given it to Tim without trying other things. And I should have researched it more before just accepting it. So now I have to undo all of this, but so far I am feeling hopeful.

Regarding the vet visit, I know your situation is very complicated. However, my female typically becomes very aggressive towards Tim when he returns from the vet. The last couple of times he needed to go for a quick check, I took them both. Same experience (except the female wasn't poked and prodded), same smell, same stress. Upon returning home, no aggression, just the normal freak-out when letting them out of the cat carriers. Maybe taking both cats will help?

Abby, Tim's progress is an inspiration.  I'm hoping my girls can turn it around too.

I came to the same conclusion as you did--bring both of them to the vet.  I made an appointment for later this month as my vet is away for a family issue.  If things worsen, I'll bring them in earlier.

The vet office suggested I offer more water options so I set up a couple of more watering holes.  I don't think it's a hydration issue...but who knows.  My girls do not drink from the fountain or bowls as they eat primarily wet food with added water.  And that was the same routine pre-constipation.  The vet office said things may change as they grow older.  

tdonline, how are your girls doing?

Tim continues to do well on his reduced dose of cisapride (we skip two days between one 5mg capsule). I thought we might be having a minor setback earlier this week when his stools really firmed up and he had two consecutive 36-hour stretches between BMs. I have some theories and made some adjustments. He is back on schedule as of Thursday morning and his stools are a better consistency, firm but with some give. It's just day by day at this point.

I am a little more distressed about my girl, Abby, who was exhibiting the same litterbox signs/behavior as Tim and has not yet fully recovered. In fact, I gave her tiny doses of miralax Wednesday, Thursday, and Friday evenings to soften her very hard stools and ease passage. She has had a movement every day, thankfully, but seems to have to work a bit to get it out. No more miralax this weekend and I am watching to see if the adjustments I made help; if not, off to the holistic veterinarian we go.

Theory 1: Too much calcium. I add homemade broth to the cats' food in the morning for extra moisture and flavor. A few weeks ago, I made a true bone broth and started using that in an effort to improve Tim's intestinal health as he was continuing to show signs of nausea. Just the other day it occurred to me that bone broth is super rich in minerals and I have since learned it is one of the best sources of calcium. I know what cats don't use, they excrete in feces and urine. I also know calcium is super important for cats, but too much can contribute to constipation. Perhaps, while the bone broth was very helpful for Tim as he is not showing any signs of nausea and has not had a pepcid ac in over a week, it was very likely completely unnecessary for Abby.

My adjustment has been to stop the bone broth entirely. I will give it to Tim on a periodic basis, like once a week or more if needed, and continue to watch him for signs of nausea and firm stools. I even stopped the regular broth with Abby for the time being and am using warm filtered water instead. I think Abby is taking longer to recover because Tim needed and used the minerals in the bone broth, while Abby excreted them.

Theory 2: Mild malnutrition, applicable only to Abby. I also add a small amount of shredded turkey to the cats' food in the morning as a treat and to entice Abby to eat. For the last several weeks she was very finicky and I realized she was picking the shredded turkey out and Tim was eating the remaining cat food. I don't know how long this went on. Between this and the added broth, I am concerned she was getting too high a proportion of her calories for too long from food that was not properly balanced for cats. Constipation can be a sign of a nutritional deficiency.

My adjustment has been to heat the filtered water to enhance the aroma of the cat food and make it more enticing to Abby. I am also adding much less turkey to her food and, in fact, am tapering what I give. Finally, I am watching them eat to make sure Tim does not push Abby away from her bowl. Thankfully, she is not finicky now and is eating very well. She is on the thin side, so I may temporarily over-feed cat food to ensure she gets the proper nourishment; essentially, give her food when she asks for it.

Theory 3: Probiotics. I had started Abby on the same probiotics as Tim (Proviable DC, from the holistic veterinarian). I know some people and animals are not helped by probiotics and my first thought was they are doing more harm than good with her, so I tapered her dose then stopped. Given theories 1 and 2, however, I am not sure and may re-start probiotics to see what happens. Or wait to see what the holistic veterinarian says.

My adjustment was to stop adding probiotics to Abby's food. I purchased plain Fage yogurt and will let Abby tell me if she needs probiotics. I will offer her yogurt and see what she does; her behavior with the yogurt will guide me.

So that's our update and I'm super interested in other opinions about Abby's (hopefully temporary) mild constipation.

Hi,
I just came across this forum and would like to share our experience with our now 13 year old Siamese cat with megacolon. Before it was diagnosed about 4 years ago he had been gaining weight and began having constipation problems. We ended up having to give him Lactulose (2 ml) and Cisapride (.5 ml) up to 3 times a day with at least monthly trips to the vet for enemas (the last couple of times, about 1 1/2 years ago, he needed anesthesia). He continued to gain weight and got up to over 26 pounds. Needless to say, he wasn't very active. His brother (same litter) weighs only about 7 pounds and is very active. After the second time that he had an enema under anesthetic, the vet suggested we try a new dry food from Science Diet - Gastrointestinal Fiber Response for felines. Since the vet also suggested that our cat lose weight, we put him on a diet of 1/2 cup per day. We do give him a tiny amount of very low fat canned food (about 1 1/2 teaspoon twice a day). So, after 1 year and 5 months on this food, we have weaned him completely off Lactulose and we only give him .5 ml of Cisapride once a day and have not had to take him to the vet for enemas at all. Plus he now weighs 21.7 pounds and is becoming more active. His stool is very soft (he takes at least one big dump each day). We are thinking of asking the vet if we could try weaning him off Cisapride completely.
He's the sweetest, most loveable cat I've ever had and we're so pleased that our vet suggested the Science Diet dry food.
I just wanted to share our experience with you.

Pops. That's Royal Canin, NOT Science Diet, fiber response.

Adore voyager, thank you for sharing your story. I am happy your cat is doing well. Chronic constipation is very scary and my goal is to keep Tim from developing megacolon.

My husband and I believe Tim's constipation was due to diet and dehydration; he was eating primarily dry food with a daily treat of about one ounce of canned food. Both times he was cleared out, the vets commented on how dry the stool was, and that it was like breaking up concrete to get it out. As such, I will never, ever go back to dry. I am also seriously on the fence about fiber, and am tending to prefer low fiber (I even pick the peas and carrots out of his canned food to reduce the fiber). I have noticed Tim has larger stools on higher fiber, which isn't necessarily better, but the frequency doesn't change. As long as his motility is good, my preference is for him to eat food that produces as little waste as possible. Keep those stools small so as not to stretch his colon into a megacolon situation.

A little off topic, but to follow up my comments from yesterday regarding Abby, our girl.

When brushing both cats yesterday afternoon, I noticed white flakes in Abby's fur that the holistic veterinarian had thought was due to improper absorption of nutrients in Tim. As such, I decided to get Abby back on probiotics, though I am giving her a half-dose. I am less inclined to think her hard stools are due to the probiotic and it may, in fact, help soften them and move them along.

I am continuing with my other adjustments, which are working out well in implementation. Abby's appetite is good and I think the very warm water added to her turkey cat food helps and she doesn't seem to notice she is getting much less shredded turkey. Upon request, I gave her a little extra food (duck) yesterday afternoon, and she still ate her full dinner portion. I started adding a bit of melted coconut oil to her dinner, though she seems to resist the texture and I have to watch how much I add.

Abby had a bowel movement yesterday afternoon after her duck snack and it was decent quantity and texture. But as she had tiny doses (~1/16 tsp) of miralax Wednesday, Thursday, and Friday evenings, I am not sure to what extent miralax is responsible. I am not giving her any more because I want to see how she does without it; she never had a single constipation problem before I started making these dietary changes to help Tim, so I truly hope undoing them for her will solve the problem (Tim is now back to normal in terms of schedule, frequency, quantity, and texture). Miralax for a few days was meant to help her along as we wait for her body to adapt to the "undoing".

As I stated before, we are on stand-by to go to the holistic vet if she doesn't produce a decent stool in 48 hours. Luckily, she's gone every day so we keep re-setting our deadline. Now we'll see what happens without the aid of miralax.

Update on Abby. Friday evening was her last Miralax dose. Saturday evening was her last Laxatone dose (this is something I would like to stop altogether, as I doubt its efficacy with either cat, but have been brainwashed by our conventional vet over many years of cat guardianship that this product is necessary). I stopped the coconut oil because, even though it is organic expeller-pressed refined, she could tell the coconut oil was in her food and wouldn't eat. Sunday and Monday evenings her stools were still small and hard, but then we saw a significant improvement Tuesday morning and this morning. Meanwhile, we visited the holistic veterinarian yesterday afternoon, who thought the hard, small stools could have been due to too much calcium, so no bone broth for Abby unless she gets nauseous.

Update on Tim. We will continue with the same cisapride dose through most of this week, then increase the days between doses to three. When we were at the holistic vet yesterday, Tim was going on 35 hours without a bowel movement, but thorough examination didn't reveal an abnormal accumulation in terms of volume or texture. But we do want to make sure he is moving things through as he should as we lower his cisapride dose and eventually take him off. So we are beginning to experiment with a bit of psyllium in order to provide support but not add bulk. I am terrified of his stool bulking up and perhaps contributing to development of megacolon, so I'll watch this closely. If the psyllium doesn't seem to have any beneficial impact, we'll stop. Tim had a nice bowel movement last night, so I think he is definitely over the effects of too much bone broth. I am not expecting another until tomorrow morning. I'll be interested to see if this is his new pattern: five days in a row at exactly 24 hours, then two 36-hour stretches back-to-back, then back on 24 hours. And I will only give the bone broth once a week or so as maintenance; I do think it helped as he has not had a Pepcid since April 3 and no signs of nausea.

Meanwhile, because I had both cats at the vet and we've been making so many changes over the past couple of months, I requested blood and urine analyses, even though both cats aren't technically due until June. Heard back from the holistic vet that both cats' results are perfect. I was particularly interested in Tim's urine, as what started this whole journey was one urinalysis that showed crystals, then antibiotics in case of an infection, then increased and very frequent vomiting, even after stopping the antibiotic. No crystals - yay! So either that urinalysis in late January was a false positive or we resolved Tim's crystals by removing fish from his diet (he'd been eating Wellness canned turkey and salmon or chicken and herring at his evening meal every day).

Both cats look really good inside and out. I'm a very happy cat-mom.

We had a somewhat bumpy week. Beginning on Tuesday, Tim started going roughly every 36 hours instead of every 24 hours like clockwork. I have to admit, at the time this made me extremely nervous. But yesterday I reviewed my (increasingly detailed) notes regarding Tim - timing of cisapride doses, amount of food, supplements, timing of bowel movements, time between bowel movements, volume, texture, and everything - and I actually now believe Tim is more in control and he's ready to move to the next step: three days between doses. We'll start tomorrow; tomorrow would have been a planned dose of cisapride, but we'll skip and dose on Wednesday, instead. Depending on how he does with this dose, we'll continue for a couple of weeks. The next step after this is stopping entirely. I'm excited for Tim (and us) but nervous at the same time.

Everything remains pretty much the same. The psyllium seems to have softened Tim's stools nicely, so I really cut the quantity because I'm terrified of bulk. Depending on his next BM, I may skip a day or so. His volume this morning was a little more than I would have liked and he had some soft pieces, but I believe this may be partially due to a new food I fed that upset his stomach. We stopped the food and, based on previous experience, need to give his tummy a couple of days to completely settle.

Abby continues to do well. I think she is one who tends to do better with a little fiber; when we were feeding Wellness canned, she continued to eat a small bit of dry on a regular basis and was perfect. But we stopped dry entirely when Tim got very sick in late January. To reduce carbs and veggie fiber for both cats, I have been picking the veggies out of the Nature's Variety Instinct. So when her stools started getting hard, I stopped picking the veggies out of her food in addition to the other things I as doing. But seeing what the psyllium did for Tim, I decided to resume picking the veggies out of her food and add a tiny bit of psyllium for her, as well. We'll see what happens with both cats. And I may stagger doses of psyllim rather than make it a daily thing.

Just a quick update - tonight Tim took his very first almost-entirely-without-cisapride poop! And it wasn't huge, so I am hopeful that we are off to a good start with this dose reduction and he will function fine without cisapride. It had been almost 62 hours since Tim's last dose of cisapride and I estimate that less than 0.5% of the medication remained in his system. It was another 36-hour stretch, but he is eating a bit less, he's eating a good quality canned food, and he had no trouble at all in the litter box, so maybe he's just a cat that goes when he's got a certain amount of waste.

Meanwhile, communicated with the holistic veterinarian and she assured me that his stools are not too large and we're not in any danger of stretching his colon. She wants me to keep him on at least 1/16 tsp psyllium to create enough bulk to stimulate his bowels. Psyllium should also help soften his stools and help them move along. This is really important now as we lengthen the days between doses and stop entirely very soon. I can go up to 1/8 tsp, and possibly more, but need to closely monitor his stools to make sure they're not getting too big. She would prefer I not mess around with his diet until he's safely off cisapride, pooping regularly, and feeling good. The reason, which I've stated, is that I need to know that any litter box changes are not due to dietary changes. So we're sticking with our current food plan.

I started another thread some time back about Tim's progress with Cisapride weaning: http://www.thecatsite.com/t/274139/cisapride-regular-vet-vs-holistic-vet. We had been doing well, but now I am feeling very nervous about our progress with Cisapride weaning. There are moments when I am afraid the damage has been done - that 9+ months of Cisapride have caused Tim to become dependent on this drug. We are going to keep pressing on, but I may return with Tim to the holistic veterinarian this week to discuss his progress.

We are now skipping three days between doses. The dose is a 5mg capsule that he takes around 5:25 each morning with his first plate of food. I did not realize this was keeping him almost on-the-dot regular until we started skipping two days. But as he was still going roughly every 24 hours, I was happy. Then he started having a few 36-hour stretches, but because the quantity wasn't huge and he didn't seem to have any trouble in the litter box, I tried not to worry and in time became okay with that. Now he is going pretty much every 36 hours, give or take, with slightly larger stools. He went 48 hours between his last bowel movements, which really worried me, and the quantity was significant - definitely 48 hours worth. We almost called the vet's office, as she has instructed us to contact her if he goes 48 hours without a bowel movement, but did not need to as he went yesterday morning at almost exactly 48 hours from his last one. He had Cisapride yesterday morning (minutes before the bowel movement, so I don't think it had anything to do with it), but hasn't gone yet this morning, which has me a little concerned; it's been 26 hours now since his last movement.

A little over a week ago, the holistic veterinarian had us start Tim on a small amount of psyllium to increase motility as we decrease Cisapride. She knows I am terrified of his stool bulking too much and perhaps leading to megacolon. We started with 1/2 capsule, which is 1/8 tsp. His next stool was pretty large, so she had us drop down to 1/4 capsule (1/16 tsp). I am blending the psyllium with plenty of water to make a liquid and smooth out any "fiber balls" before mixing with his food. But I am not sure it's working for him, as his frequency hasn't increased, yet his stool size has a bit. I sent average stool measurements to the vet and she does not think he's in danger of megacolon. But I'm just so nervous right now.

Tim went through two terrible constipation episodes where he had enemas and was hospitalized for a couple of days. We did not see any warning signs and didn't know he was sick until he was vomiting and panting; we rushed him to the emergency vet both times. After the second episode, we made changes to his diet by transitioning him to wet food. I'd like to get him on raw, but the holistic vet is worried about transit time while he's on Cisapride. At the same time, I am worried he will have to remain on Cisapride. From what I recall, when he gets constipated, he just stops going. We did not see straining or unproductive visits to the litter box; we are unsure about appetite as we were free-feeding back then; there was no elimination outside the box. The only thing we noticed, as we alternate litter box duties, was less; each thought the other was scooping all the poop. Now we share our litter box findings to avoid this in the future.

Each time we reduced Tim's Cisapride dose, he had a "lag", where it seemed his body needed to adjust to the reduced dose. Perhaps this is what we are seeing now. But 48 hours! And no poop (so far!) the day after a Cisapride dose! Both are a little concerning. I will just need to watch him and if we have a second 48-hour stretch, back to the holistic veterinarian we go. I am not going to change anything with Tim until I discuss with the vet, but for discussion purposes, is anyone aware of anything natural we can try that would stimulate him without increasing the bulk of his stool?

Any thoughts are appreciated.