Gut issues: Deciding whether to give my cat steroids (prednisolone)

[stephenq]

Anyone know how long I should expect to want to see results from prednisolone? Today is day 3 of 5 mg and the vet wants to start tapering down tomorrow. But she's still not better, only really eats with a lot of prompting and since yesterday an appetite stimulant, still meatloafs after eating, still has diarrhea.....

Wait a sec where are you right now diagnostically?  I ask because you generally don't put a cat on Prednisilone (in the context we're discussing) unless you suspect IBD usually because the cat is loosing weight and not responding to other therapies.  If it's working you can expect weight gain in a week or so (maybe measured only in a few ounces, baby scale at home is important) but gain is gain, and if you get weight gain, then the cat is [probably going to be on Pred a very long time, possibly for life or at least for as long at it is giving your cat remission.

If it's working and your vet suspects IBD, i don't have any idea why he/she would want you to start tapering so soon.  If its working, its saving your cat's life.

 

[samus]

That's why I'm so confused! I still need to get a scale so I don't know if she's gaining yet, last vet visit was before the pred and the loss had slowed. I think the vet doesn't want her on so many drugs because the kidneys? I think there are also different cultural attitudes towards drugs here, like they should only be temporary and very minimal. (If you try to get just plain old Sudafed or cough syrup here you're likely to get sold weird herbal stuff instead.)

 

[stephenq]

That's why I'm so confused! I still need to get a scale so I don't know if she's gaining yet, last vet visit was before the pred and the loss had slowed. I think the vet doesn't want her on so many drugs because the kidneys? I think there are also different cultural attitudes towards drugs here, like they should only be temporary and very minimal. (If you try to get just plain old Sudafed or cough syrup here you're likely to get sold weird herbal stuff instead.)

Can you tell us where you are?

If you're confused then we're confused.  One can't judge the value of Pred without weights for the cat prior to giving the pred and after.  At the very least you need to see weight gain during the course of the pred to judge that its working.

This is as clear a "flow chart" as I can make:

1- Cat has long term diarrhea and/or vomiting with no obvious medical cause, all easily testable causes are ruled out.

2- Vet makes a presumptive diagnosis of IBD because there is really nothing else to diagnose, but disease is mild, no weight loss.

3- Various treatments are tried (Tylosin, Metronidazole, B12, pepcid, and food trials over many months, etc), and they either work long term or not but eventually if they stop working then:

4- Cat starts to loose weight. Disease has become serious/severe.  Decision is made to Biopsy or not. Ultrasound probably reveals thickening of intestine with loss of layering.  IBD or Small Cell Lymphoma is strongly suspected. And even without a biopsy, or even without an ultrasound see #5 below.

5- Because of #4, cat is put on Prednisolone.  If weight starts to gain in 1st or 2nd week (even measured in ounces) then this helps confirm diagnosis of either IBD or SCL, and cat stays on Pred because the Pred is keeping the cat's disease in remission until #6 below.  *Note: if initial dose of Pred doesn't help then an increase in dosage is worth trying.

6- Pred stops working, weight loss and possibly serious GI issues return, other drugs are tried and either they work or #7 below.

7- Cat dies or is PTS (Put To Sleep).

IMO, if any of the above is skipped or not understood, then there is confusion, and the potential for inadequate or incorrect diagnosis and treatment.

Prednisolone doesn't have any specific issues with kidney problems.  Pred can cause diabetes so that needs monitoring, and because it has the potential to lower the immune system, blood values need regular re-checks.  But with severe IBD or SCL, all the risks of Predisolone are worth it because the alternative is #7 above.

I've been through all the above through #7, so I've really been there.

 

[samus]

Ok, this started with her eating poorly for a couple weeks, then not eating at all (maybe a couple bites a day) and looking pained in the litter box. I thought she had a UTI and took her to a vet. Urinalysis wasn't conclusive (she peed on the table, not a sterile sample), but no blood or cloudiness so the vet thinks she was constipated. Felt what she said felt like really hard poop in her bowels on palpation. (Blood tests taken, showed slightly high creatinine and super high eosinophils.) Gave her some psyllium, GIANT solid poop later. Also prescribed antibiotics, and had as injections this first visit: ammoxicillin, metaclopramide, H2-blocker, cerenia, lactated Ringer's. She ate more than she had been when she got home, but was back to minimal eating the next day.

This didn't help the appetite, still only eating maybe 40-50 calories a day (she was 3.35 kg at the first vet visit a couple weeks ago). Tried turkey and rice baby food, massive diarrhea. Got a prescription food (horse and parsnip), she ate that for a few days and didn't have diarrhea, but it was still only 50 cal/day. Then she stopped eating that, and there was some vomiting, back to the vet, 3.15 kg now. Sometime in here I started syringe feeding. Got a dexamthasone shot and cerenia, switched antiobiotics (from I think clavamox to marbocyl). Half a week later got an ultrasound and another dex shot, but only lost about 30 grams since last visit. Appetite slightly better, up and down across all these vet visits. Gave her oral cerenia two of the days in this time period, didn't help the appetite or meatloafing. But maybe she doesn't absorb stuff orally so well?

Despite her anorexia, she seemed really hungry and was eating crumbs off the floor and trying to steal bread, so I went out and got a bunch of different cat foods to find if there was one she would actually eat. Diarrhea came back. It started when I fed her turkey baby food again because she really needed the calories, then some other cat foods with turkey were in the food trials (and lactose free milk, and plain cooked ground pork). Today is day two of only pork and horse. I even stopped the slippery elm. Pork is basically novel, she's only had it in a dry food she was on for about a month three years ago. Maybe also once or twice in something with "byproduct," but I don't usually get foods like that (unless maybe Fortiflora had pork protein in it's "digest?"). Hoping I can get her back on 100% horse so there's only one protein to worry about, but she only eats it mashed with the pork. Or that her digestive tract decides pork isn't offensive.

Sunday I started subq's (50 ml/day), and the marbocyl was finished. Tuesday I started 5mg prednisone/day. Yesterday I started giving the appetite stimulant. She's been getting omeprazole (2 mg) for about a week. Now she's eating, but still with the diarrhea and the looking nauseous (licks her lips a lot when I put food in her face) but no vomiting for a few days. The weight loss has definitely slowed, I'm waiting for my scale to get here and see if there's actually gain.

I really haven't seen any change that I could tie to the prednisone. It didn't seem to significantly increase her appetite, she's still clearly in pain. I don't understand why the vet only wants to do three days of 5 mg, it doesn't even seem long enough to see if there's an effect. I can't get in touch until Saturday, trying to decide if I should keep on with the 5 mg or taper like she asked me to. I'm leaning towards keeping on with the 5 mg until I talk to her, it's only one day longer than she said... I think there's a kidney dimension in there too making everything worse, but her numbers are only barely out of the ordinary.

I'm in Germany.

 

[Columbine]

Just wanted to say that you're both in my thoughts. It's just that I don't have the knowledge to chime in and help you with this.

 

[samus]

Thanks, I really appreciate it. I mentioned my issues to a few of my colleagues and the line of conversation seems to keep going, "And how old is she? Do you think maybe it's time....?" It's not time! She still cuddles and does that weird thing where she suckles on her fur when she's comfy and kneading and following me in the kitchen for food and lying on my pillow in the morning. She only hides under the couch if she thinks I look like I'm about to stuff pills in her face. She went on the patio this morning. She's still totally interested in the world.

 

[Columbine]

It doesn't sound like 'time' to me at all What I do know of ibd is that it can take time to stabilise - especially in the early stages. Once you find the right regime things should get better for her

 

[samus]

Let's just forget about the part where I was supposed to go out of town for a few days after Christmas.... I don't know what would be worse, leaving her home alone with someone stopping by that might or might not be able to successfully pill her, or putting her through the stress of either staying in a hotel for a few days (let's just assume the hotel agrees) or boarding her somewhere. (I don't even know how that works, would she be in a cage for a week??)

 

[donutte]

So many people thought it was time for Lucky the day I got his diagnosis, without even trying to wait the two weeks before testing again. If any of those folks saw Lucky in the vet's office that day they wouldn't have even known he was sick. My vet got to meet the real Lucky that day - twitchy tail, tummy-up and all - after he got his subqs at the office. People just don't *get* it it seems.

 

[zed xyzed]

 
Thanks, I really appreciate it. I mentioned my issues to a few of my colleagues and the line of conversation seems to keep going, "And how old is she? Do you think maybe it's time....?" It's not time! She still cuddles and does that weird thing where she suckles on her fur when she's comfy and kneading and following me in the kitchen for food and lying on my pillow in the morning. She only hides under the couch if she thinks I look like I'm about to stuff pills in her face. She went on the patio this morning. She's still totally interested in the world.

It makes me happy that your are fighting for her. I am wishing you both good health 

 

[goholistic]

I apologize in advance if I bring something up that's already been discussed. This is all such a mystery to me, @samus. Most of the literature out there says that elevated eosinophils are indicative of allergies and/or parasites. Of course, there are no absolutes with these types of things and elevated eosinophils don't always mean this.

In looking at your summary there, it seems she didn't develop diarrhea until after that first heap of treatments (she had hard BMs prior to this). Perhaps it's possible that the antibiotics threw her gut balance out of whack and gave her diarrhea? This is not uncommon. Please remind me...why were the antibiotics prescribed in the first place?

Also, you said she's licking a lot and seems to be in pain, and wants to eat, but can't. Has her mouth and throat been checked? How about under her tongue? It does seem more like a gastrointestinal thing, but with all these treatments not really helping, I had wondered if it was something else. I remember a story of a cat licking a lot, seeming to be in pain, and not eating much, and it turned out to be a mass under the tongue.  

I wish you had some answers, and I'm hoping for the best for your girl. 

 

[samus]

Right, the diarrhea didn't start until the antibiotics, but also switching foods (multiple times). I've been giving her probiotics (Proviable, something from the vet with only Enterococcus faecum and inulin, past couple days Biokult) with no change. She hates Sacharromyces boulardii and even if it's inside a buttered capsule she knows and foams like crazy, so I haven't been able to really give that a try. The antibiotics were initially because of a suspected UTI (straining when using the bathroom, teeny little flakes of urine in the litter box instead of big balls...) and I'm not sure why we continued with them after the UTI test was likely negative. But she did have a few solid poops in the middle of antibiotic treatment, so maybe it's more food related?

Food allergies are pretty likely, she's had mild symptoms for years (flaky skin and occasional vomit), but when I tried to do an elimination diet three or four years ago she got hepatic lipidosis so I gave up. I dewormed her (Milbemax, one dose, not sure if I should do a second just in case?) when this all started, but multiple checkups previously have shown no sign of parasites in the poop even while her eosinophils were high.

I plan on asking the vet to have a good look at her mouth, tomorrow if there are any appointments open.

 

[samus]

Solid poop!!

(Why is there no poop emoticon on this site?? It's so relevant!) And yesterday she ate almost 170 calories! Still meatloafing, though. But solid poop!!!!!!!!!!!!!!!!!!!!!

 

[Columbine]

:hobbes:
Great news!!!! I really, really hope the eating and solid pooping continue

 

[goholistic]

 
Solid poop!!

(Why is there no poop emoticon on this site?? It's so relevant!) And yesterday she ate almost 170 calories! Still meatloafing, though. But solid poop!!!!!!!!!!!!!!!!!!!!!

 That IS great news! 

  Vibes that it continues!  

Sorry that the s. boulardii didn't work out.

 

[samus]

I've heard so much good stuff about S. boulardii (for humans, too!), but it just tastes like poison to her. Maybe a different brand.... Next time I'm desperate to stop a diarrhea run I'll probably try it again.

She has really been gorging herself the past two days! 250 calories a day! And that's without the appetite stimulant and with the prednisolone tapered to 2.5 mg since Saturday. And she weighs 40 g more than Saturday, too, over 3 kg again. I don't know how much cats vary with water weight, though.

Still meatloafing, but that's been normal for a while. The vet wrote me a prescription for Dipyrone/Metamizole, but I haven't picked it up yet. Seems like it'd be more of a symptom masking thing than figuring out what's causing it (gut, kidney, or both??). Now that the diarrhea's gone, I think I'm going to start slippery elm again (earlier I wasn't sure if it was contributing to her general ugh, the first time I gave it to her she seemed really bloated). And I'm going to see the vet again Wednesday, maybe we can try calcitriol.

 

[Columbine]

Fantastic that she's still eating well Mega for her continued progress

 

[samus]

Things are still going well. She's been eating 200-250 calories a day and has gained about 60 grams in the past week. Nice (but gigantic) poops, too. A few days ago I skipped her prednisolone (she's on 2.5 g) to see if it could be tapered even more, and the next day she was gagging after she pooped. Not sure if it was related, because she'd also had diarrhea a couple days before (ran out of prescription food and the vet was closed) and might have still been recovering from that?

I'm worried about going out of town for Christmas. A pet sitter is coming over daily (possibly twice daily, we'll see), but I don't know if she'll be able to pill my cat. It's relatively easy for me, but when strangers handle her (like at the vet), my cat gets kind of bitey. My vet gave me the option of picking up a dexamethasone injection so I could inject her right before I leave. The injection lasts 3-5 days, so it's just about perfect for the amount of time I'll be gone. Anyone have experience switching between steroid types?

Luckily she seems to not notice when I put the omeprazol beads on her food, so at least getting her those pills should be easy.

 

[stephenq]

 
Things are still going well. She's been eating 200-250 calories a day and has gained about 60 grams in the past week. Nice (but gigantic) poops, too. A few days ago I skipped her prednisolone (she's on 2.5 g) to see if it could be tapered even more, and the next day she was gagging after she pooped. Not sure if it was related, because she'd also had diarrhea a couple days before (ran out of prescription food and the vet was closed) and might have still been recovering from that?

I'm worried about going out of town for Christmas. A pet sitter is coming over daily (possibly twice daily, we'll see), but I don't know if she'll be able to pill my cat. It's relatively easy for me, but when strangers handle her (like at the vet), my cat gets kind of bitey. My vet gave me the option of picking up a dexamethasone injection so I could inject her right before I leave. The injection lasts 3-5 days, so it's just about perfect for the amount of time I'll be gone. Anyone have experience switching between steroid types?

Luckily she seems to not notice when I put the omeprazol beads on her food, so at least getting her those pills should be easy.

As to tapering, personally I wouldn't do it without a vet's ok.

Will she eat pill pockets? If yes, then the cat sitter's job is much easier.  At one point in my cats IBD illness we had to give shots of Dex, mainly because the Pred had stopped working, and all i knew was that Dex is stronger.  I'd be worried about changing steroids with you not there to help if there was a problem but i suppose switching is better than not getting anything at all.....so back to the pill pocket question?

Can you have your cat sitter demo giving a pill for you, so you can see how good they are at it?

 

[kflei]

Has the vet discussed possible megacolon?  The gigantic poops make me wonder; seems worth mentioning.  I would also highly consider taking her to another vet for a second opinion- reading over this thread, I don't have a good feeling about your vet...

"Megacolon can be a frustrating disease for veterinarians, owners, and, most importantly, for the affected cats. The disease develops when the muscles within the wall of the colon (large intestine) no longer contract as they should. Feces builds up and dries out within the colon, resulting in constipation.  Most cases of megacolon are idiopathic, meaning we don’t know why the condition developed in that particular individual. Less frequently, an injury, developmental disorder, or other primary condition prevents the colon from emptying as it should, causing it to stretch and stop functioning normally. In either case, cats with megacolon typically:

• Strain to defecate
• Exhibit pain while defecating
• Have abdominal discomfort
• May lose their appetite
• Produce small amounts of hard fecal matter that can contain blood or paradoxically produce small amounts of liquid feces, leading their owners to wrongly diagnose them with diarrhea"

  http://www.petmd.com/blogs/nutritio...dietary-management-of-megacolon-in-cats-30472