Nausea, vomiting_enlarged prostate_natural or prescription treatments?

Mal - almost 16, neutered male diagnosed w/ CKD - probably stage 4.
He was actually doing pretty good after being diagnosed. Some of the rapid changes could be coincidence, or directly connected to things.
I need some good suggestions on his nausea, vomiting & enlarged prostate.

Right up till he was recently diagnosed CKD, he was eating & continued for a 7 - 10 days.
But soon after seeing the vet - the 2nd time, & switching to Hill's K/D "with chicken," he lost appetite - started syringe feeding.

He tolerated 78 - 80 ml of pureed home made meat food or the Hill's very well - even gained 1/2 lb. Never a problem throwing up.
Soon started vomiting meals - long after he'd eaten - 6, 8 or more hrs. That part confused me. This was very sudden.

Now, he's been diagnosed w/ enlarged prostate - can also cause nausea. He IS neutered. Likely explain the feces being flattened, with outer oval shape, about 1/4" thick.
Thought he was constipated, but after Miralax & several enemas, appears the prostate was the issue. At least, best guess for now.

But nausea / vomiting meals long after eaten is big problem. Hasn't held a full meal/ completely emptied stomach in several days now.
Vet gave Reglan - called it great for gastric motility & nausea. but many comment there are far better drugs for nausea (really depends on the cause).
He may / may not just have acid reflux. If not, H2 blockers or PPIs won't help. Other than trial, how do you tell?

Vet gave short script for Finasteride 1mg, take 1/2 tab/D off - off label (I think this is Propecia). He said, "no drugs commonly used for feline enlarged prostate."
Does everyone agree w/ that, or have vets prescribed (effective drugs) for enlarged prostate?

It's enough of a problem, needs to shrink some. Of course, a chance of cancer or prostate infection, inflammation. Not sure how they diagnose prostate infection.
Or, if there's a "kitty PSA test" for elevated antigens?

I'm not sure whether to use famotidine / ranitidine (zantac), or a PPI. I used 1/4 tab of Pepcid on him, but not regularly for weeks, because it only suddenly became a (real) problem. Some say PPIs are more effective, but also have more side effects in most humans.

He's on fluids - vet just increased from 100 ml to 200, daily. After the vet visit y'day, & new fluid volume (2 injection sites), he didn't feel too good (not that he'd been feeling great last 4,5 days. Was that coincidence from drive to vet & being prodded a lot? Or, the 2x increase in fluids - latcated ringer's solution? Today, feels much worse.

I did give ~ 5 mg protonix (PPI) today. Waited ~ 1 hr, then gave home made chicken broth. He held it, but then for last ~ week, he'd held the Hill's for 6, 8 or more hrs before vomiting most all back. Often when I'd give him a small syringe of water or some meds. Was apparent that his stomach wasn't emptying.

I would say start with famotidine 1/4 of a 10mg tab a day (of course make sure your vet's on board with all of this before you do it). Give that a few days, if that doesn't work, try ranitidine. I don't know the dosage for that one as I've only ever used famotidine. I wouldn't use a PPI unless those two don't work.

Those are all for hyperacidity. For nausea, have you tried Cerenia? I would ask the vet if you could have that regardless if he is constantly throwing up.

I know you have the other thread also, so this makes me worried about a blockage if he is throwing up consistently, and oftentimes hours later. Is he throwing up his entire meal, or is it just foam?

Thanks. When I mentioned to vet something specific for vomiting & for gastric emptying (often most of previous meal), he said he gave me the Reglan.
When I mentioned Cerenia for nausea & cisapride for motility - as ones people often mentioned, he acted like he'd never heard of them or knew very little. (But he also knew little about using phosphorous blockers, or types).

True, the PPIs or H2 blockers will only help nausea / vomiting, if caused by excess acid / reflux. If general nausea - from blood toxins or the general CKD disease - even side effect of enlarged prostate (mentioned often), they won't help much. (People w/ flu, & many other diseases aren't nauseated, vomit because of acid).

If the PPIs or H2 blocker w/ Reglan don't help quickly, I'll have to look elsewhere. Unless he does 180 deg about face, as for getting meds often mentioned on such forums / med sites, I'll likely have to see another vet. Then I'll need anti nausea, anti anxiety & antidepressants meds - for sticker shock (seriously).

Mal has held down the chicken broth (home made, not additives) - last couple times, in small doses - 12 - 15 ml. He may hold more at once as time progresses (soon). It's some improvement. No point in overloading him if just vomits it. He seems to feel a little better today (not even "good" yet).

QUESTIONS ON SUB-Q VOLUMES: Vet decided to raise his daily LRS from 100 ml/daily - that he got for ~ 10+ days (need to check), up to 200 ml/daily.
I wondered about sudden, large increase (he's not actually dehydrated).
If that in itself could cause serious increased lethargy & "acting sicker" symptoms (in a cat)?

Sat 5/28 - 1st nite gave the 200 ml (2 inj, sites). After, he seemed more lethargic than before - as in, acting seriously ill.
Sun 5/29 - was his worst day by far - worse than after getting enemas.

so, Sun. nite 5/29 - reduced LRS to ~ 125 ml. Of course he didn't perk up instantly, but Mon morn seems much better.
Yes, Sun. he got the PPI, Reglan, Finasteride (*possibly* shrink prostate), - not sure any would have that fast an effect. Or if it had more to do w/ LRS volume?

As I mentioned on your other thread, cats can, indeed, get over hydrated.  This information is taken directly from the website that I also referred  on your other thread (felinecrf.org):

Symptoms Associated With Overhydration                                                   

http://Fluid Retention/Build-Up

Sometimes a CKD cat may develop fluid retention or fluid build-up. A cat with fluid retention may:

• 
  exhibit loss of appetite, because the fluid may be pressing on the stomach causing a feeling of fullness.
• 
  find it uncomfortable to lie down on his or her side, or may sit up and refuse to lie down; this is because it is easier to breathe in this position.
• 
  appear to be gaining weight rapidly or suddenly (within the space of a few days)
• 
  be breathing faster (see Diagnosis for normal respiration rates)
• 
  start coughing
• 
  purr with a rattly noise
• 
  develop a nasal discharge
• 
  have runny eyes
• 
  start breathing from the flanks (as if pushing every breath out)

Fluid retention may be a sign of worsening kidney values  or of heart problems, but in many cases it is actually  a sign of overhydration from either intravenous fluids (IV fluids) or subcutaneous fluids (sub-Qs). Some vets believe it is impossible to overhydrate a cat through sub-Q fluids but unfortunately this is simply not true. Over the years, I've heard from quite a few people whose cats developed precisely this problem. In Renal disease (2006), Dr D Polzin states "Chronic subcutaneous fluid therapy can result in fluid overload in some patients, particularly when fluid volumes in excess of those recommended here are used. We have seen several cats given large quantities of fluid (200 to 400 ml/day) present with severe dyspnea due to pleural effusion. This condition can usually be avoided by reducing the volume of fluids administered."

If your cat feels "squishy" when you stroke him or her, this may indicate fluid retention caused by overhydration from excessive sub-Qs (although sometimes it merely means that air got into the line, in which case you need to work on your sub-Qs technique).

As far as as his enlarged prostate, could that be from a bacterial infection?  Have they checked?  I haven't been able to find anything associated with enlarged prostates and nausea, so not sure there is any connection there, although there, so am wondering if the nausea is due strictly to his kidney issues.  If that's the case, the possibilities are seemingly endless.  Check out THIS portion of above referenced website to see if any of these (other than possibly overhydration) fit the bill:  http://www.felinecrf.org/nausea_vomiting_stomach_acid.htm.  My old kidney guy had just the frothy vomiting, and we were able to keep it at bay with the Pepcid A/C twice a day and Ranitudine 3 times a day.  With my little girl cat, we controlled it most of the time with Pepcid A/C every other day or so, and VERY FREQUENT small meals.  I'm talking about 8 - 9 meals per day, two of them in the middle of the night.  Always wet food, with extra water added.  Usually about 3 hours apart, usually about .75 oz to 1 oz of food per meal.  This worked very well for her.  And sub-qs 3 times a week.  She was stage 4 when she passed, and didn't actually die from kidney disease. 

BTW, instead of chicken broth, have you tried BONE broth?  It's much more nutritious.  Takes at least 24 hours to make, but may be worth it. 

Thanks, Mrsgreenjeens (how's the mister?), Lot of good points & questions - some w/ no clear cut answers - yet.
No, didn't think of "bone broth" - definitely check. This is all new & dozens of decisions / find info on multiple health issues, not just CKD.
Yes, I saw the section on fluid retention / over hydration. I didn't notice any of the described symptoms, but not an expert.

By today, Wed 6/1, he's more reactive (not "well" or chipper - still very sick). Last few days, he hardly acknowledged me. This morning he walked over to me / looked at me / sniffing, while I was at Kit. Meowed fairly normal "hello." Sat right beside me - hasn't done any of that in days. Who knows - the sum of all meds may be starting to make small diff; or got past stress of long vet exam Sat and / or ? any reaction to increasing sub-q to 200 ml. Haven't given that much since - just 125 ml /D. Had gotten 100 ml/D for couple wks.

He is strong enough, has enough energy (A couple times / D) to drag 6 lb weighted, make shift water "bowl," all over the kit & into Brkf Rm. Puts both paws on rim & back peddles. If don't weight it, he tips & spills regular bowls constantly. I fabricated another he likely can't move, but then thought - this is good exercise.

Think I'll make a separate Prostate post - separate, urgent issue. I'll reply to your question there.

MOD NOTE:   We have moved this post here from another unanswered thread about the same issue. 

@CatOMight had put a lot of information in it that probably is already addressed here, but it seemed a shame to just delete it.

____________________________________________________________________________________________________________

Mal - nearly 16, neutered @ ~ 6 mo; recently diagnosed w/ advanced CKD (Stage 4, unless #s improved, after started treatment).
History of FLUTD / struvite / cystitis - but no serious cases in 12 yrs. Ate low carb, low phosphorous canned or home made diet all his life, until switched to Hill's Rx by vet.

* Vet & I thought he was constipated / had impacted stool. May HAVE been constipated, but not impacted; not from dry stool or lack of fiber.

* Much discussion later & finally prostate exam, vet says his prostate is fairly enlarged. I had to show him the lump.
* No test has been done yet to find the type of prostatitis (inflammation; Squamous metaplasia; cancer, etc.). Probably fairly expensive.
* Apparently causing difficulty / straining to squeeze soft, moist stool past restriction, "flattening" the feces to ONLY ~ 1/4 in. THICK;

* Problems emptying bladder, some dribbling; some incontinence when handle him.
* Intermittent blood in urine (could be prostate, cystitis, CKD - any or all, in any combo - different times).

Vet said there're NO ACCEPTED, ROUTINELY used meds for feline enlarged prostate. But prescribed "short dose" of Propecia (finasteride) - sometimes used in humans for enlarged prostate. Per the vet, "sometimes in dogs, but not cats." Seems to be more info on the web about canine prostatitis than feline.

The Poll:

1) What did vets prescribe / do for cat enlarged prostate (already neutered)? Whether Rx, herbal, OTC or a combo; or surgical / physical methods?

2) Once prostate enlarged enough to press colon & flatten feces and / or reduce bladder emptying, what reduced swelling enough to pass normal shaped feces & improve bladder emptying?

3) How much did feeding Hill's K/D renal diet, or similar foods w/ added dietary fiber increase typical fecal diameter?

4) Did feeding Hill's / other renal Rx canned diets raise urine pH (if ever measured)?


Some notes:
* Most enlarged prostate (in men) are not cancerous
* He gets daily sub-q fluids, plus CKD - increasing urine - making swollen prostate even more urgent.
* Extra, "bulking" fiber is often not recommended with any bowel constriction / obstruction.

* Meds or foods that increase urine pH are not good for his type FLUTD / struvite / cystitis issues. [High carbs in Hill's K/D & many kidney Rx foods tend to raise pH
* Some renal diets are reported to INCREASE serum / urine pH, to combat mild acidosis. Good for CKD, bad for struvite FLUTD. (haven't called Hill's yet)
* Treatments / meds for any of his 3 distinct conditions may not be best for the others; possibly contraindicated.

* Hill's Rx foods (esp. renal) contain fair amount of fiber - psyllium (soluble & insoluble) and INsoluble "Oat Fiber" - adding bulk. Though soft, makes bulkier stool hard to pass w/ enlarged prostate. Other Rx brands & regular foods often added bulking fiber . Squeezing larger than normal dia.stool to 1/4 in. thick doesn't work well.
* Unless / until his prostate shrinks, may need a suitable lower residue diet & daily osmotic stool softener (Miralax, Colace, Lactulose). Else, he'll have problems passing bulky stool. A home made diet may be needed to meet CKD, prostate & FLUTD needs.

The Reglan doesn't seem to be working well (as some cautioned it may / may not). It may help some, but unless I feed very small meals or just broth (neither will be good for long), he still often throws up. He can tolerate / hold broth, but can't live on it forever. Making "bone broth" to try.

Except for Miralax (if feeding solid food) & things that need to mix w/ the food, I give meds at least 30 min - prefer 1 hr before meals. I don't know if they're being mostly absorbed by the time he eats, should he vomit, or if they're wasted doses.
Partly depends if they're absorbed by / in the stomach or small intestine; and on stomach motility (or lack of) - if they need to get in small intestine.

Even testing ~ 5 mg of Protonix (PPI) WITH the Reglan doesn't stop vomiting food. He doesn't vomit clear liquid or foamy. Often, he'll hold the 1st meal, then many hrs later - after another small meal (~20 ml of 50/50 broth & canned food) he vomits. It's a pattern. I'm guessing lack of stomach motility + nausea.
Also suggests possibly that acid / reflux isn't main cause of his nausea.

He's also on aluminum hydroxide (not weeks yet) - may help some w/ nausea.
For last several days, held SQ @ 125 ml/D. May ease up to 150 - see if any improvement.

Tmrw, if able, I'll call another vet about diff meds (several have mentioned & I've researched them); & possible course of treatment - it all may be financially unreachable.
I imagine he needs BOTH anti nausea (Cerenia) & prokinetic for motility (cisapride).
And if anything they can do to shrink his prostate - cost to find out the type Prostatitis & treat; or may just suggest antibiotic w/o confirming infection (seems like a shot in the dark).

Other, large "all cat" vet clinic sites mention other late stage treatments - if anyone has experience / comments.
* Stanozolol, also known as Winstrol - can use w/ SQ fluids - "can prolong the life of the kidney twice as long as SQ fluids alone." Has side effects, but now - that's not much of an issue.

APPETITE STIMULANTS: Mirtazipine or Cyproheptadine is what they use.

Azodyl: all cat clinic said they use this - they say, "helps bind to proteins in your cat's intestinal tract..." Expensive.
But ingredients are: "Azodyl is a propietary formulation of beneficial bacteria". "Contains Enterococcus thermophilus, Lactobacilus acidophilus, and Bifidobacterium longum." This looks like a probiotic - can buy these anywhere & I'm not aware these bacteria "bind proteins". They may help DIGEST proteins.

Benazepril or Enalapril. " helps to minimize protein loss in the kidneys..."

Procrit. "In a small percentage of CKD cases, we will also see anemia from destruction of centers in the kidneys..."

Thanks. Gotta go squirt food down him.

The only thing I can say to using Mirtazipine is that it worked pretty well for my kidney cat (we used it transdermally since pilling was not an option for her), BUT, if your guy is vomiting his meals, then I don't see any point in increasing his appetite until you figure out the cause of the vomiting.  Once you get that under control, say with Cerenia, then he may want to eat again.  If not, then certainly you might try one of those appetite enhancers.

Azodyl is something many people use, but the pill size is HUGE, IMHO.  If you're good at pilling, I don't see why not.  My guess is all these meds are discussed on that website I've been referencing.

Just a thought...have you tried Digestive Enzymes with him.  They help break down the food.  Just thinking since he's vomiting food so many hours after it should be out of his tummy, maybe he needs help with enzymes in his stomach, although typically when food is still in the stomach that long it IS either a a motility issue in the stomach or else some sort of obstruction.  (again, my reference is that website) 

I wish I knew what to tell you.  I think seeing a Feline Only Vet might be your best bet, though, particular concerning the prostate issue.  That's a completely new one on me regarding cats. 

For anyone: after started cat on cerenia (assuming stopped vomiting) - how long before they could hold near their usual meals - whether eating on their own or syringe feeding?

"have you tried Digestive Enzyme"

Click to expand...

Yes - still give them. Whether "best available for cats" - not sure. They're Now brand Plant Digestive Enzymes. Many I've seen in cat products. Lots of confusing info & good bit of snake oil, I'd guess. Also give probiotic - formulated "for babies." Neither may work miracles, but probably won't hurt.

The cerenia (and / or w/ the mirtazapine, Reglan) seemed to completely stop vomiting. May ? have helped the motility (or cerenia & Reglan) - hasn't thrown up after 2nd, 3rd, Nth meal of day. But not up to normal volumes yet.

Something in 1 or more drugs seemed to make him fairly groggy / lethargic. Still moves around, but often in kind of a daze.
Vet 2 said keep giving Reglan (only 1/4 of ? 5mg tab, not 1/2 tab as Vet 1 gave) w/ the 8mg Cerenia/D & Mirtazipine (1/4 tab - 3.75mg - 1x every other day). Or could be feeling worse - from disease. Seemed to worsen after starting cerenia - though tolerates more food & holds it down. New meds often make people feel "out of it" for a time - some never tolerate a drug.

In animals w/ serious disease, very hard to know if somewhat negative behavior changes are from drugs or the disease.

Some cerenia trial studies show some (dogs) had drowsiness / lethargy.
A European *field* study showed (not lab study): http://www.drugs.com/pro/cerenia.html

Drowsiness/Lethargy/Apathy: % occurrence: placebo - 1%; cerenia - 8% - in 107 dogs.

Reglan sides effects include http://www.webmd.com/drugs/2/drug-6177/reglan-oral/details#side-effects
confusion, depression, Drowsiness, dizziness, tiredness, trouble sleeping, agitation, headache, and diarrhea

Mirtazapine side effects include http://www.drugs.com/sfx/mirtazapine-side-effects.html
Decreased or increased movement; mood or mental changes, including abnormal thinking, agitation, anxiety, confusion, and feelings of not caring;
mood or mental changes. More common: Constipation, dizziness, drowsiness...
Less common: Abdominal or stomach pain, increased need to urinate, increased thirst, nausea, trembling or shaking, vomiting, weakness

All 3 have potential for mood altering effects, lethargy / drowsy, "spaced out."

If I fed a cat 8x / D -middle of nite - I'd be worse off than the cat. Make so many mistakes dosing meds, possibly make very sick / kill him.
Not gotten him past 35 - 37 ml food pr meal since started cerenia - on 6/4. N He's obviously filled out a bit, since cerenia.

How's he doing now?   In answer to your question, with chronic illness,sometimes you can NEVER stop the anti-emetic without the nausea returning, so you have to weigh your options. 

I hear you about being extremely tired while I was feeding 2 meals in the middle of the night.  Yes, I was tired, but I worked out a routine where it only took me a few minutes, really.  I had the food ready and sitting on an icepack next to the bed.  Just needed to take it out of the ziplock bag and feed it

Are you able to give several of the meds together and use an empty gelcap to do so?  That's helpful, but sometimes the meds have to be given at so many different times that it doesn't work.  With our old girl, we did transdermal meds and injections.  It worked well for her...NO pills at all.

Hope your boy is feeling somewhat better.

"How's he doing now?"

Click to expand...

I'm sure he feels much better. He passed on, late Wed. eve., 6/8 - 6 days after seeing vet 2. He's not in pain any more. Can't be sure, but don't know if he ever experienced a lot of "pain." Feeling lousy - yes. Uncomfortable from constipation for a while - we got straightened out pretty quickly & he was running normally again. And it wasn't enlarged prostate (apparently). Vet 2's ultrasound showed "mass" pressing on both the bladder & colon.

He was doing somewhat better after getting crenia to stop vomiting & start holding down fair amt again (syringe). He wasn't making huge recovery, but not getting worse.
Had a very sudden downturn. It's odd that only a few days after starting to hold food, he passed. He got fairly close to normal diet volume in last few days. Then declined quickly.
The med(s) that stopped nausea, helped some symptoms may also have caused his demise. They have long list of side effects. Some are serious or potentially fatal - like in Reglan, along w/ cerenia, mirtazapine.

The last 10 - 14 days, except for a few occasional min., he didn't want to sit w/ us, though stayed in same room. The day he passed, he stayed on the couch mostly.
The last several hours, he stayed right between us while we petted him. He seemed to know we were comforting him, but who knows since they can't talk. He may've only been in a semi-conscious state. In his last half hour, he reached out & touched my arm & hand a couple times. May be unconscious reflex - who knows.

In vet 2's incredibly brief blood work ($92), his PCV = 15%. Normally 35 = 40%? Indication of anemia. Not sure if that was main cause of death?, but anemia came on suddenly. On 4/28, blood work sent to lab didn't do PCV, but showed:
WBC = 8.8 (5.5 - 19.5 ref); RBC = 8.25 (5.0 - 11.0); HCT = 36.3 (25.0 - 45.0). The * only* out of range CBC tests then were MPV = 8.5 (12.0 - 24.0) & "MID%" = 23.3 (0.0 - 12.0). A Vet 1 physical exam - weeks after 4/28 didn't show physical anemia signs (he demonstrated).

Vet 2 did NOT mention on 6/3 the 15% PCV just run or implications. Not its meaning, possible causes, value's importance / severity, possible temp. / long term anemia treatments of ANY type - or "hopeless," Seems like it was kinda important? Vet mentioned his anemia (unimportantly, "by the way") & I asked about B vitamins. Later in exam notes, she ridiculed me for asking about them or anything else that might help him feel better, if only temporary.

I may post a few questions later. As I have severe chronic pain & fatigue diseases myself, I'm still worn out after well over a month of extensive care & research. Constantly trying to tweak meds, supplements, testing foods, begging vets. From date of diagnosis - soon after 1st symptoms, till he passed - only 42 days. I was going full tilt the entire time. I know the vets let him down in certain respects - failing to mention several critical things, misdiagnosing an easy to see / feel problem; not prescribing properly or wouldn't change ineffective meds. I feel like I let him down - I may've done a much better job if I wasn't so freaking fatigued all the time.

I'm so, so sorry.  As you say, he is no longer suffering, if indeed he was in life

Having recently lost one of mine, I do know what you're going thru.  It's heartbreaking, especially if you've been together MOST of those 16 years.  My girl was also 16.

Again, my sympathies.