Artie and his Issues

1. Have you begun taking care of yourself again?  The last I heard you'd been neglecting your thyroid medications and were feeling the consequences.
2. If you're unwell, your emotions are going to be all over the place, no matter what.  It is extremely dangerous to make life and death decisions when you can't trust your own emotions.
3. You're still in the stage where you're figuring out what does and does not work for Artie's illness.  His drugs and dosages clearly need adjusting, and the vets have made it obvious that they're not going to do that; you are the only one who can.  If Artie isn't nauseated, don't give him nausea medication, unless the S. Vet gives you a reason other than nausea why Artie needs it.  Ask specifically why Artie needs the Reglan when he isn't nauseated.
4. I think (and remember, I'm not a vet) that the next step is figuring out exactly how much of the motility meds are needed to keep Artie's poops normal.  Normal pooping means nutrients absorbed.
5. I think your subconscious is telling you that you need a month to work on it, to figure out what does and does not work, through trial and error.
6. If nothing else seems to work, and Artie is miserable, please remember one last option -- a feeding tube.

Artiemom said:

@margret the S vet has not mentioned anything else about the Reglan sine I told her I was not giving it to him. The only motility drug he is on is Cisapride. Nothing else.

Not coming to the defense of the s. Vet, but she has not insisted on Regina sine I said NO.

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cat-tech said:

 
Artiemom,

Having a trained eye, I can see some potential issues that may be able to be corrected.  Please forgive this lengthy post - since I am rarely here, I want to be thorough as I may not get back to the post soon.  Feel free to run some ideas by your vet.

Food schedules and GI transit times - because Artie has a chronic condition, it might benefit him to be on a scheduled feeding - I'm concerned you're leaving canned food out for him overnight (yuck).  A consistent feeding schedule keeps his routine consistent, his food fresh, and allows his GI tract a normal transit time for digestion and  a better chance for more regular elimination.

Example:  morning, noon, evening (please do not leave food out all night for it to go rancid).

Smaller, more frequent meals can help ill cats maintain consistency, as well as offer better absorption, easier on the stomach and intestines when digesting smaller meals, and allows a longer and more restful period overnight.  Resting overnight could help him feel better enough to be excited about his morning meal, then his noon meal, then his eve meal, encouraging consistent meal amounts.  If he eats 1-1/2 cans of food in one sitting, that could be hard on him to rest comfortably, digest properly in an optimal transit time.

Thanks, but Artie has always been free fed. He does better at free feeding. He has a constant supply of food and nibbles during the day. I am home, so I limit the amount of food that is sitting out. Most of his food intake seems to be while I am in bed, sleeping.  I have central air in the summer, and keep the house cool. I also add water to his food to keep it moist. When it looks dry, I toss it. Yes, I waste a lot of food..

Diet - does the vet approve of both types of diet you're feeding?  Has she really evaluated the ingredients well enough to conclude they are appropriate for IBD?  I understand this may be the only thing he eats or his favorite, but you also want to make sure it's not contributing to the problem (unneccessary or "fad" ingredients, fat source/content, etc, check for suitable fiber content and nutrients).  And, the "clay" substance you mentioned in the ingredients, not sure I'd want to feed that to my cat. The cycling between chronic constipation and diarrhea could be contributing to weight loss, obviously, but it's important to make sure the diet is ideal for nutrient availability, determining if the rabbit version could be causing problems and if a different protein source, limited ingredient or hypoallergenic diet might be considered.

Artie is the type of cat who will starve himself, rather than eat anything he does not care for. I have tried all the prescription novel proteins, to no avail. This seems to be the only line of food that he will eat. Yes, the 'clay' is concerning, but I have researched it. I have not found any adverse effects from it, listed on the web. I have exhausted my search. I am really careful with trying to get him to eat the prescription food rather than the NV line. He refuses all other proteins. For a short period of time, he was eating lamb, so I stocked up on that. He is allergic to chicken, so his choices are limited....

Likewise, depending on the appropriate novel protein, the right one could also help alleviate the stomatitis to some degree, ask the vet about this in case it's been overlooked.  

Re-evaluate the timing of meds - check the prescription labels or call your vet to confirm/advise if one or more should or should not be given with food, and spaced apart appropriately because so many meds given can interact against each other if given together or too close together in a short time period.  For most meds, having a small amount of food fed before giving meds helps absorption and helps to decrease nausea as opposed to meds given on an empty stomach.  (Try giving his morning meal, then waiting 1/2 hour to give morning meds - the same with afternoon and eve meals).  One or more meds could be given at the noon feeding instead of morning meal, which takes the stress off the number of meds given at morning and night.  Either way, talk to your vet about this so she can tell you which meds, if any, should be given further apart from another, which meds more beneficial in morning, eve, etc.  

I have a plan as to which foods need to be given on an empty stomach and which ones can be given at any time. 

With all the meds, you should have a daily "chart" in your daily diary to mark off specific meds to give, when to give, when given, etc so there is no confusion or forgetting which meds have been given or need to be given.

I have made a "Flow Chart" listing all of his daily meds.. I have made it up for the week and check off each one when it is given. This way, I do not forget of get confused. I made the flow chart, this past week-end and are tweaking it, in order to get it right. My dad had one also, so I am accustomed to the concept.

Review your diary with your vet and observe patterns where you increased/decreased meds and Artie's diarrhea/constipation increased/decreased, timing of food etc.  I do hope you have obtained your vet's advice for adjusting doses on your own? (i.e., the lactulose and miralax) - as with feeding, consistency is also the key with medications. Consistency is usually ALWAYS better than sporadic dosing, so perhaps be more consistent with the doses, and ask if smaller doses on a more consistent schedule will help.

The Specialist is sometimes hard to get in touch with. I have been told by my Regular Vet that I have a clear understanding of the meds. She is on board with me adjusting things around. She knows that I will always contact either her or the Specialist if I have a concern. I would never go cold turkey on anything. 

I was told to stop the lactulose, after I stopped it on my own--based on Artie's symptoms. The same with the miralax. It seems I have a 'handle' on things. I am consistent with the dose, unfortunately, these drugs are "dose to desired effect" and it takes a couple of days to see a change..

Probiotics - may not be necessary and some types can cause gas in the intestines in some cats - they should really only be used in some cases of diarrhea or for some cats who require lengthy antibiotic treatment, etc.  Unless your vet has a specific valid reason for using the probiotic, ask her if it can be ceased.  The medical community has conflicting opinions for and against the use of probitiocs whether short or long term, and there are studies questioning their usefulness for the conditions probiotics are prescribed.

Probiotics seems to be a 'given' for any cat with IBD. I know the use of probiotics in humans is controversial.. Personally, I have microscopic colitis. I have been though the route of probiotics. The use in cats is that it is supposed to help restore the balance of bacteria in the gut.. All IBD cats do take them.. as far as I know.. and a lot of MegaColon... just my understanding.

Pepcid - I'm not sure why Artie is on pepcid, it may not be necessary and a side effect is constipation - a possible alternative if necessary, consider ranitidine (zantac) but only on direction of your vet -since this seems to be better suited for constipation, but it is not without certain precautions.  Your vet also has other options available.

Pepcid:  it is for any chance of acid formation in his stomach. It is given automatically because the assumption, since cats cannot tell us, is that there is nausea associate with IBD.. and it could help with it...

I can ask the S Vet about it.. but I do not foresee her reducing that..

Cerenia - may not be necessary if no nausea or vomiting - it is also recommended to use caution with this med in patients with heart disease - there are no studies done on long-term use in cats and the manufacturer only recommends short-term dosing.  I don't know the reasoning behind the vet's wanting to use cerenia, but if it is because of off-label use claims, many claims have not been verified nor researched (I've seen cerenia off-label use touted by vets for everything from pain control to anti-inflammatory use, but no research has been done for safety and effectiveness of these uses).  Off-label use of some drugs can be incredibly useful in medicine, but red flags might be up when those uses are across the board and anecdotal.

Yes, I agree. I would love to see Artie cut out the Cerenia use. I do not feel he is nauseated, but the S Vet is adamant about keeping him on this, just in case. My gut feeling is that, once we get over this phase, and get him on a schedule of normal; that is when we can think/talk about eliminating Cerenia. I think it was because of the constipation and lack of appetite, and weight loss. The Specialist is trying everything she can to make eating easier for him, while allowing him to poop normally.. We are just going with his symptoms.. nausea is sometimes hard to understand in cats because they hide things so well.

The Cerenia did work awesomely when he was having a flare.. 

So far, if your vet agrees, there's three meds that maybe could be omitted from the routine.

Lactulose - ideally, you should be keeping the daily dose consistent and ONLY adjusting the dose when diarrhea becomes excessive - ask the vet her opinion on this.  Same with the miralax - consistent schedule, perhaps smaller doses.

Lactulose is only to be given when he is straining or his poops look hard. It is my 'go to" drug..

B12 injections - vitamin B12 injections have a relatively good safety margin and are helpful for absorption and some cats' appetites have improved.  Injections are usually only given once a week and less often after an initial period, depending on response.  Ask your vet about this.

I really do not get an answer on this .. He did have a B-12 and folate level done. I think I will have them send me a copy of the report. 

Fluid therapy and needles - Do NOT freeze needles, this can sting much worse than an initial insertion of a room-temp needle, it could also alter the sterility of the needles - imagine your physician injects you with a frozen steel 18-gauge needle, think about that.  Also, sarcoma issues in cats - it's not just VAS causing sarcomas, it is theorized that other injections could be culprit, any injection could cause an inflammatory response, we just don't have enough data and research to conclude.  I'm not saying you have to worry about sarcoma from injections, I'm saying don't fix what isn't broken, don't cause an inflammatory response by improper use of needles.

OMG... this is the first time I have heard of sarcoma issues form sub-q's.... now another thing to worry about!!??? 

​I have never read anything about this. And freezing the needles is a tip I read from several sites which explain how to give sub-q's... are you sure about this?

Fluids do not need to be warmed unless they've been stored in a cold room, if they are at room temperature, it's fine. Warm fluids can help comfort an ill cat, or help raise body temperature in a hypothermic cat, but otherwise warming is not necessary.  If you feel he appreciates warming the fluids, then go ahead and do so, just saying it's not usually necessary.  Please confirm with R-Vet whether fluids administration should be 50ml or 100ml  twice a week- she and S-Vet need to be working together and sharing case notes, not telling you two different things.

I used the warm fluids the other day. Artie did not jump or shiver when the fluids began. I am believing that warmed fluids are better for the cat.. My Vet warms the fluids also.   and I have been advised that the dose is 100 mg twice a week. I have triple checked this..

Obstipation - S-Vet is concerned about obstipation because it could indicate loss of function, require manual or surgical removal of impaction (and yes, repeatedly, this means anesthesia every time, stress, hospitalization, stress on his body), and megacolon can develop as a result of chronic constipation or obstipation.  Chronic constipation is already a painful and debilitating condition, no one wants to see a kitty have to endure repeated procedures/hospitalization when meds can help prevent it!  Maybe she was blunt, but she wanted you to understand why it was important to prevent it.  

Yes, she was blunt about this.. I understand about obstipation. I think she was scaring me to get her point across. She does not seem to have people skills. I get it.. I understand why she prescribed the Reglan. I wanted her to know that the side effects were not good for him.. what kind of a life is it to have a cat who is constantly drugged out... that is no life for a cat.. just as a drugged out human has no kind of life at all.

Megacolon - S-Vet or whomever diagnosed megacolon should be telling you if it is due to Artie's chronic constipation, a stricture, possibly from a prior pelvic injury, etc, and if additional diagnostics are warranted to determine appropriate treatment.  I see in your notes there is a neurological component, but did anyone tell you how they plan to address it?  Whatever the cause, could explain why Artie is having so much difficulty.  Hopefully, the priority is focusing on getting his IBD under control and hopefully no additional diagnostics, but I didn't see in your posts if there was a diagnostic plan in the future or not - I'm just concerned that if there is an issue with megacolon, and something is left unaddressed that could complicate his IBD and overall health.  Talk to R-Vet and ask her if this is a wait and see approach (by focusing on the IBD) or what.

After going over the ultrasound, x-rays of abdomen, and his history with the Radiologist. The conclusion was raised that Artie has a neurological motility issue which can/will eventually lead to MegaColon. The Reglan was prescribed to help with the neurological issue.. however, the side effects were horrible for him..(see above comment)

I honestly feel his IBD is under control. We are now dealing with the constipation issue.. the diarrhea has been caused by the treatment of his constipation.. Once we get that under control, God Willing, we should be ok.. 

It is a trial and error period right now......as it is with humans and any chronic disease they have. Sometimes you have to try a multiple drug approach ~~~ which is trial and error.. until you find the correct drugs and dosages...

Please follow up with your vet - depending on when Artie's last blood work was done, you may want to recheck the chemical profile and cbc, and talk further about that heart murmur (make sure it is not progressing to something else).

Artie has blood work done every six months.. His last one was done in October.. 

We were in discussion about him having an echocardiogram in the spring...just as a checkup on the murmur.. but that has taken a back step due to his current issues..

Hope this helps.  Hang in there and try to be optimistic.  IBD can be managed in most cases, but it does take time, and adjustments in diet and medications to find the right balance takes time. Don't give up!

Thank you for your thoughts, and advice. I do appreciate them. A lot of what you have mentioned, I have already been through. It has been a long road with Artie.. I think I have covered just about every base with him. I am doing my best as to finding and tweaking his medications. 

Yes, IBD is so frustrating.. compound it with a motility issue....which is not all that uncommon.. wonder if that could be related to IBD??? I asked the S Vet about that, she said that no one knows the answer to that.. 

I think more research has to be done into the relationship of IBD to motility issues leading to MegaColon. I wonder if they are all one and the same.. IBD leads to Mega or motility issues.. Just think about the diagnosis. IBD is an inflammation of the lining of the colon. IF the inflammation worsens, it makes sense that the nerves will be damaged, leading to motility issues.. it does not all need to be from the pathway from the brain.. it could be right there in the diseased colon.. 

The problem is creating and finding a drug which can work in the intestine, allowing the diseased nerves to either           re-generate or find pathways around.. I think that is why the Reglan was prescribed. It works on the neurological pathways from the brain. too bad there is not something which can help locally....

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