Ongoing Pancreatitis/Triaditis

[skiptomylou]

I need help. My 12 year old cat has been struggling with this disease for two and a half months at this point. There is no known cause. Nothing foreign or toxic ingested, never had any signs of IBD. She was initially hospitalized for five days starting July 5th and she had a feeding tube installed and supportive care. She came home in much better shape and easily accepted the tube feeding. The medications at that time were dehydrocholic acid (synthetic bile), cerenia, buprenex and gabapentin for pain, vitamin K, and elura. She was being fed the ROYAL CANIN liquid recovery diet, until I ran out and it was on backorder everywhere and I switched to Emerald Sustain. She had several re-check appointments where her bloodwork eventually shows normal levels of everything so we were told to stop the synthetic bile acid and just keep giving her the cerenia, elura, and pain medicine until she started eating enough on her own, then the tube could come out. When after several more weeks there was no improvement with eating on her own another ultrasound was performed which shows pancreas still inflamed. A tapering dose of prednisone was started as well as another month of synthetic bile acid (which are awful sticky pills). She's on her 5th week of pred and I stopped the synthetic acid pills after 30 more days of them. Meanwhile, in a desperate attempt to get her to eat on her own, I switched to Mirataz as the appetite stimulant which works great for her. With one third of a dose I can get a solid 48 hours of full meals plus some extra out of her. She still isn't eating on her own though. As soon as that dose wears off she stops eating or barely eats. She scratches at the tube a lot and has a lot of obvious buildup of mucous or something in her throat and I had stopped all meds except the tapering dose of prednisone and the mirataz because it seemed like she was doing ok without them so I made an appt yesterday for another ultrasound followed by the tube removal. The ultrasound still shows inflammation of pancreas, stomach, and part of the liver so she was hesitant to take it out. After a discussion we decided to leave it in, which honestly made me feel more comfortable right now but I know my cat has had enough of it with the scratching and crap in her throat all the time. Even though I rinse the tube with 10 ml of tepid water after every use it would sit unused or barely used for a couple days and then I would try to use it again it would be clogged which has never been a problem before. I can get it open with about 3 ml of Pepsi but I have to do it every single time I use the tube which doesn't make sense. Anyway, after yesterday's ultrasound the vet extended the pred, which I'm fine with, started B12 shots at my request, and suggested I consult an internal medicine specialist. She has also gone from 11.4 lbs her whole life to 9.9 lbs despite eating like crazy lately which indicated malabsorption to me, hence asking for the B12 shots. I asked her how long it is safe to have a feeding tube in before an esophageal stricture develops and she is researching it. This is not the original tube. She pulled that one out about two weeks after it was put in. I tried for a week to get her to eat enough on her own but she wasn't and I couldn't get any meds into her so I had another tube put in. Then she ripped the stitches out on the new one but I managed to keep it in her for 7 days until our next appt. where they put extra stitches in and so far so good. All of this and the multiple appts and med pickups have been done at the emergency vet that admitted her which is an hour away. We are both tired of the ride and lack of progress in recovery. She always remained pretty tired and only occasionally leaves my bedroom. Other than that she grooms and eats great with the mirataz, purrs and makes biscuits when she sees me. I am about 9K into this at this point and there's not much improvement. I don't really want to spend another few thousand to get the opinion of an internal medicine specialist. My regular vet seems to think 2 months with a feeding tube is too long but I know people have left them in longer and had a successful outcome. Does anybody have any experience with this awful frustrating disease and anything that helped? I know recovery can take a long time but how long is too long? Should I keep her on the pain meds even though I've seen her look much worse? The buprenex has the same effect as the mirataz in that it makes her kind of hyper and slightly agitated so I probably wouldn't be able to give the two together. Should I give the elura more time, even though I tried it for two months already? She would eat the next meal following the elura dose but then would have no appetite again, but the elura doesn't make her hyper. Should I start the cerenia again for its anti-inflammatory properties even though she doesn't act nauseous? Sorry this post is kind of scattered...it's just been a long frustrating two and a half months and I don't know what else to do. I have three cats, but this one is my soul cat. She has been since the day I found her in a feral colony. She is also blind from a terrible herpes infection that took her eyes most likely from birth and after spending her whole first year getting the infection under control I had what was left of her eyes removed at a year old.

 

[Furballsmom]

Hello, I don't recall exactly how long it took for Poppy to recover from his triaditus (realizing that every cat is different). He didn't have anything particularly specific that caused the illness. He was about 14 years old at the time, but it definitely did take a number of weeks. A couple of differences in the treatment for your cat are that Poppy was prescribed sub-q fluids which we administered daily at home, and denamarin, then eventually we switched to milk thistle. I don't remember how his eating was because since he was uber finicky, and so I had to handfeed him in order to get the supplements in him.

Again, I can't stress how different cats are, but if not a specialist, maybe a different cat-only vet?

You are being redirected... this link is to a directory for cat friendly and cat only veterinarians.

 

[skiptomylou]

Thank you for your response. I will check out the link for cat only vets. We do have one about a half hour away from us. I forgot to mention the denamarin in my original post but she was sent home on the denamarin and took it for 2 weeks or so until it was gone and her bloodwork since then indicated that she didn’t need it anymore as her liver values were back to normal. I have not done sub-Q fluids at home but she did have them while hospitalized. After recovery, did it ever return for Poppy?

 

[white shadow]

Hi S skiptomylou !

Pancreatitis and triaditis have to be the most frustratingly difficult conditions of all.........and the toll they take on us!

There is a specialized online community of folks who are managing their kitties pancreatitis/triaditis. They've been active for sixteen years with nearly 1200 members, so there's lots of practical experience and support available there. You can find them here: Feline Pancreatitis Support.

Now, while I know they will have experience with tubes and tube feeding, there is also a similar ("specialized") group whose focus is tube and assist-feeding. So, while expertise in the pancreatitis group is related to treatments, these folks' focus is on the nitty-gritty detail/techniques related to the tubes.....again, with years of experience. They are here: Feline Assisted Feeding.

[Now, these groups use email as their 'operating platform', so the "look" is different from a forum like this, and it takes a little getting-used-to. From my experience, the best way to manage the information flow is to get a brand new email account (like G-mail) just/exclusively for the group. That can keep things organized for you.]

I hope that this can help - from a practical experience perspective, groups like these cannot be beaten.

And, just a 'btw' on that find-a-cat-vet site...........under "Practice Type', select "Feline Only". [this "friendly" business is just marketing hype!]

Meantime, keep us posted and, of course,.................we'd love to see the patient

 

[Furballsmom]

After recovery, did it ever return for Poppy?

Not directly, no but his liver numbers and pancreas numbers always remained higher than our vet preferred. She called him one of her pancreas kitties.

 

[silent meowlook]

Hi. I have known cats to have feeding tubes in for years. Usually it is replaced if there is a complication, also it depends on what type of tube is used. But as long as all is well, leaving it in months is fine, even longer provided there are no complications.
What color is your cats tube?
If your cat is scratching at it, there may be a problem with the bandage or there may be a little infection in the area the tube is inserted. How often are you having the bandage changed?
To prevent blockages of the tube, you can flush with warm water 20 mls.
If the tube becomes clogged try flushing gently with water.
Always keep track of the total volume you are giving your cat so as not to exceed the capacity of the stomach.

I think referring to an internal medicine specialist is a good idea if you can do it. Things like this are complicated. When the ultrasound was done, was it a specialist doing it?

 

[skiptomylou]

white shadow thank you for the helpful links. I have heard of both groups before but never pursued them as it was confusing how it worked so thanks for the explanation!

S silent meowlook her tube is red. The ultrasonographer is not a specialist however she has been doing and reading ultrasounds for 23 years. All three ultrasounds my cat has had she has been asked if this looks like a cancer and all three times she said no, although I know no definitive diagnosis can be made without a biopsy which I won't put her through. She doesn't have a bandage around the collar for a long time now as the insertion site is healed. She has a kitty kollar which I remove at least once a day to scratch underneath and check the incision site which is always dry and doesn't smell. I was told that some dry scabbing is normal, which she does get. I am guessing that some or all of the scratching is/was due to her ears having some sort of infection which I have finally been able to clear up with the proper medication. Originally they thought it was ear mites but after two different vets looked at the debris under a microscope and neither found any sign of live mites, dead mites, or mite droppings they switched gears. I have figured out the last few days that if I mix up a small amount of her Emeraid formula and sandwich the meds with that the tube isn't getting clogged. Plus it gives her an extra 37 calories each time. I just allow her to eat her regular food, wait an hour or so, then do the small amount of Emeraid with the meds. I am always super cognizant of how much I am putting in there at a time because I am terrified of her vomiting due to me "force" feeding her.

Pain management I think is now where I'm struggling the most. I have buprenex and gabapentin. She does ok with buprenex but I don't want to give it along with the mirtataz as both have a tendency to cause hyper activity and aggravation and I don't want her to go into serotonin syndrome. So I've been using just gabapentin, only .3 ml liquid twice a day as more than that really knocks her out. Since cats are so stoic it's so hard to tell if/when they are in pain or just tired.

I'm thankful to the people replying so far for letting me know that two and a half months of having the tube in is ok. My regular vet leaves me with the impression that I'm being selfish for leaving it in "this long" and that if it's not better by now it won't be and I'm just leaving it in for me. I felt pressured to have it removed, and when I took her back to the vet at the emergency hospital that put it in she didn't want to remove it yet, and I'm very grateful she didn't as I've used it a few times since. So many conflicting opinions everywhere. I have had several chronically ill animals in my life, in fact they tend to seek me out, so I am able to tell when it is their time and when they don't want to try anymore. She is not there yet and I'm just so tired of some vets and just people in general trying to tell me that I'm being selfish.

 

[silent meowlook]

Can I ask you why you are giving the Mirtazipine if you have a feeding tube in place?
Also, have you thought about a reduced dose of buprenorphine if it causes hyperactivity?

 

[white shadow]

Curious, what/which form of buprenorphine are you using? (unsure if you're employing "buprenex" as a generic term) I've only experienced the sedative effect from buccal administration, while (here on the forum) we've seen extreme excitation with long acting, 'spot-on' and transdermal formulations - these appear to have 'extra' additives which are causing this.

Cyproheptadine might be an alternative to Mirataz, no fear of serotonin syndrome with it - more here.

Just from what you've said here, I think you'd likely benefit from that first group.The mechanics are quickly mastered, and initially you could just observe and assess the quality, expertise and usefulness, a test-drive so-to-speak, then get involved or 'take a pass'. There's little to be lost in that!

 

[white shadow]

I knew there was something missing here............did you see this?

and, of course,.................we'd love to see the patient

 

[skiptomylou]

S silent meowlook I am supposed to be trying to get her to eat on her own in an effort to get the feeding tube out. Without any appetite stimulant she barely eats anything, which I know shows either nausea (which she’s on cerenia for, I tried zofran but it didn’t really make a difference), or pain. We tried daily Elura for 2 months but it didn’t last long and she would only eat the next meal following the dose and that was it vs two full days of meals with the mirataz. Plus I wanted to find something I could get in her for when she does eventually get the feeding tube out. I tried but there’s no way no how I’m getting the Elura into her mouth. I wish it did work for longer because there really seemed to be no side effects from it. I can’t reduce the dose of buprenex anymore as she is only getting .1ml through buccal administration once or twice a day. It seems to have a dual effect on her…it makes her tired but at the same time extra paranoid so she’s jumping at everything. Does this effect eventually get less as they get used to the medication? Remember she’s blind so she’s already really sensitive to sounds. The mirataz gives her energy but it also makes her frantically lick at her front legs/chest/shoulders so it’s take a few steps, frantically lick, take a few steps, frantically lick, and so on.

white shadow as requested…pic of the patient

 

[silent meowlook]

It’s hard to say with the buprenex. It does make some cats more hyper. I forgot she was blind. What about reducing the Mirtazipine? Do you think if you did a half dose it would still maybe increase her appetite?
She may not want to eat much on her own because of the tube. But, by no means do you want to remove the tube because she isn’t eating well and you need to be able to get food into her.

If it was my cat, I would skip the Mirtazipine and continue the buprenex for now. I would also not be to concerned about her not eating on her own as I would be tube feeding. I would give it a week and then start to see if she wanted to eat on her own. This I would do to avoid or reverse any food aversion she may have. I would also get referred to an internal medicine specialist. I would also make sure her hydration is good and supplement with subcutaneous fluids if not. This is just what I would do if my cat had this going on.

She is absolutely adorable and if that picture is fairly recent she does look content there. There is no way I would give up on her if she was mine. But of course I am not rite there with her and don’t know. I would support, as I am sure anyone here would, any decision you make with her. It is very obvious how much you love her and judging from that picture, she knows it too.

 

[skiptomylou]

S silent meowlook this picture is from last weekend. I'm only giving her a third of a dose of the Mirataz now but I can half it and see what happens. It's interesting how appetite stimulants work great if it's a food the cat already wants but if the cat doesn't like it they STILL won't eat it even with the stimulant. Cats will be cats whether in a nutritional crisis or not! Her hydration seems fine. When being tube fed she gets a lot of water and when she decides to eat more on her own she drinks a good amount. I was hoping the past 5 weeks of pred that she was on would've done more to get rid of the inflammation but they haven't seemed to. I'm under the impression that the Cerenia is not only good for nausea and vomiting but also for inflammation so hopefully at some point, between the two, her body decides to cooperate. I'm not sure if food aversion is what is going on, as she will act offended by food before an appetite stimulant but then give her some mirataz, wait an hour, and she thinks that same food is great. I don't know. I wish they could just tell us in words we understand what hurts and how to help them. Thank you for offering your opinion on all of this. I don't post much but I lurk a lot and I know you're quite knowledgeable about veterinary topics.

 

[skiptomylou]

A general question…has anybody actually given low doses of mirataz (as in 1/3 of the recommended strip) with a low dose of buprenex (as in .1ml) and did anything negative come of it? She really does so much better while getting the mirataz and getting proper nutrition. She hasn’t had any since Friday morning and she ate up until last night (Monday) with that same dose but now she’s barely eating on her own at all again and looks like she feels like crap despite getting both buprenex and gabapentin.

 

[silent meowlook]

Yes, I have given reduced doses of both. Sometimes it works and sometimes it doesn’t.
if you think she is better with the full dose, by all means do it. Are you syringe feeding her the required amount of calories for her?

 

[skiptomylou]

I am doing my best to get her daily calories into her but it’s a little difficult with the emeraid to determine exactly how many calories she’s getting. If I go by the mixing instructions on the bag they want slightly more powder to water. If I mix it like that I can’t get it through the syringe. So I mix it half and half, which I’m sure throws the calories off. It was a lot easier with the Royal canin recovery/convalesce liquid she came home from the hospital with because it was pre-mixed and I knew she was getting 1 kcal per ml but it’s been on back order for months because these companies like to play games with their consumers. Before the mirataz I’ve caught her eating her litter a few times which says nutritional deficiency to me which is also why I’m starting the B12 shots. When I give her mirataz she eats really well and a good amount of dry food as well which really helps get calories into her. And she also comes downstairs and seeks out food and our laps which she really doesn’t do otherwise since she’s been sick. She’s currently having a herpes flare up from all the stress of the disease and all these long trips to the vet and staying there all day with barking dogs and chaos. Ugh so frustrating.

 

[skiptomylou]

Come to think of it I wonder if the anti-depressant properties of mirtazapine also help with her. Like she really does just look happier while on it

 

[silent meowlook]

I would just continue it. It’s all about feeling better. Whatever makes her happy. Can you see if your vet can get or has the HILLS science diet A/D? It is similar to the recovery. Might make things easier. I have used what you are using now. ( phone won’t let me spell it and keeps putting in “ embrace” instead) anyway, that stuff is annoying .

 

[skiptomylou]

They do have A/D and I am going there tonight to pick up more gabapentin anyway so I will just get some. I’m assuming you need to mix it with some water to make it a little thinner? The emeraid IS a pain. My phone always wants to turn emeraid to emerald

 

[silent meowlook]

I use as little water as possible and usually use one of those bullet blenders. That’s if it is too thick to go into the tube.