TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

   

ERYTHROPOIESIS STIMULATING AGENTS (ESAs) FOR SEVERE ANAEMIA

The information here was recommended by Catwatch,

the newsletter of Cornell University College of Veterinary Medicine, May 2011

 

ON THIS PAGE:


What are ESAs


When to Use ESAs


Types of ESAs


Commonly Used ESAs (Aranesp, Epogen, Procrit, Eprex, NeoRecormon)


Obtaining ESAs at Reasonable Prices


Dosage and Usage Guidelines


The Downsides of ESAs


Should I Use an ESA


Feline Erythropoetin


 

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Home > Treatments > Erythropoiesis Stimulating Agents

 


Overview


  • Anaemia means that not enough red blood cells exist in the body. It is relatively common in CKD cats, so it is important to know about it and to be prepared to deal with it.

  • Treating anaemia in a CKD cat is worthwhile: University of Georgia College of Veterinary Medicine states that "anemia is not a poor prognostic indicator in cats as most live for more than 300 days despite presenting with anemia."

  • Mild or moderate anaemia may be controlled using various treatments which are discussed on the Anaemia page. This page deals with a form of treatment for severe non-regenerative anaemia called erythropoiesis stimulating agents, or ESAs.


What are Erythropoiesis Stimulating Agents


 

The kidneys produce a hormone called erythropoietin which stimulates the bone marrow to make red blood cells. As the kidneys fail in CKD, they cannot produce enough erythropoietin, so the bone marrow is not stimulated, blood cells are not produced, and a particular type of anaemia called non-regenerative anaemia results. Non-regenerative anaemia may have other causes, but this is the most common reason for it in CKD cats.

 

In addition, a uraemic toxin called parathyroid hormone, which is not processed properly by damaged kidneys, may also adversely affect the production of erythropoietin.

 

Cats with mild anaemia will be offered various treatments (see the Anaemia page). However, cats with severe non-regenerative anaemia (PCV or HCT below 20%) caused by CKD often need artificial erythropoietin in order to control their anaemia. The various forms of artificial erythropoietin are collectively known as erythropoiesis stimulating agents (ESAs). They are usually very effective, and in fact one human study, Anemia management and the delay of chronic renal failure progression (2003) Rossert J, Fouqueray B & Boffa JJ Journal of the American Society of Nephrology 14 pp173-177 found that "treatment with epoetin may slow the progression of chronic kidney disease."

 

Unfortunately after a few months of use a small percentage of cats may develop a reaction to ESAs, commonly referred to on CKD support groups as the antibody reaction, which stops them working.


When to Use Erythropoiesis Stimulating Agents


 

Some vets seem to rush to use ESAs as soon as a cat is diagnosed with anaemia. Others seem to be terrified to use them because of the risk of an antibody reaction developing a few months after starting ESAs. Depending upon the severity, type and cause of the anaemia, there are other treatments which may be more appropriate and which are certainly cheaper. See the Anaemia page for more information.

 

The basic criteria for using ESAs are as follows:

  • The PCV or HCT (a measurement of anaemia) will be between 15% and 19%, or even lower, and the cat will be showing signs of anaemia, such as breathlessness, lethargy or severe loss of appetite. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 mentions that the Animal Medical Center in NYC considers a PCV below 20% to be the level at which treatment with an ESA should be considered.

  • The cat should have non-regenerative anaemia rather than regenerative anaemia. A reticulocyte test can confirm this, although this test is only accurate if the PCV or HCT has been below 20% for five days or longer.

  • The PCV or HCT should not have fallen suddenly, e.g. from 24% one week to 17% the next. Most cats with anaemia caused by CKD become anaemic gradually which means their bodies have had time to adapt to it to a certain extent. Cats who develop sudden, severe anaemia should be checked for other causes, such as gastro-intestinal bleeding.

  • Usually (but not always, particularly in older cats) the CKD will be relatively advanced, with creatinine over 5 (450 international), at least at initial diagnosis. This indicates that the kidney damage is probably more severe, and therefore the kidneys are unlikely to be producing sufficient erythropoietin on their own.


Types of Erythropoiesis Stimulating Agents


 

There are two categories of ESA which have been used in CKD cats:

There has also been a study into the feline erythropoetin gene, and another will be commencing shortly at the University of California at Davis.

 

Unfortunately, neither feline erythropoietin nor the feline erythropoietin gene are commercially available at present (October 2011). I do discuss below the current situation regarding research into these treatments, but this page focuses primarily on the treatments which are currently available for you to use, in the form of human erythropoietin.

 

Human Erythropoietin (ESAs)


Since feline erythropoietin is not commercially available, most people whose cats need erythropoietin supplementation will have to use human erythropoietin. It takes the place of the cat's natural erythropoietin and enables the bone marrow to continue to make red blood cells. 

 

There are a number of different types of human erythropoietin, as outlined below. Although these products all have the same goal, technically they are not exactly the same, so they are referred to collectively as erythropoiesis stimulating agents (ESAs).

Epogen, Eprex or Procrit (epoetin alfa)


These are all types of the epoetin alfa variant of recombinant human erythropoietin:

  • Epogen, made and sold by Amgen, is the synthetic version of epoetin alfa used in the USA for the treatment of anaemia in human CKD patients on dialysis.

  • Procrit is the same product, epoetin alfa, made by Amgen but sold by Ortho Biotech in the USA for the treatment of anaemia in human CKD patients who are not on dialysis. It is also commonly used for cancer patients with anaemia caused by chemotherapy.

  • Eprex is the version of epoetin alfa made by Janssen-Cilag in Europe for the treatment of anaemia in both dialysis and non-dialysis human patients. It is also used for human patients with anaemia from other causes, such as chemotherapy. Whilst Eprex is a form of epoetin alfa, it is not identical to Epogen/Procrit.

See below for the dosing protocol for Epogen, Procrit and Eprex and how to obtain it at a reasonable cost.

 

NeoRecormon (epoetin beta)


Hoffmann LaRoche make a form of recombinant human erythropoietin called NeoRecormon. This is epoetin beta, rather than epoetin alfa (Epogen, Eprex or Procrit are epoetin alfa). It is becoming more common to use NeoRecormon in Europe for cats with non-regenerative anaemia caused by CKD.

 

See below for the dosing protocol for NeoRecormon and how to obtain it at a reasonable cost.

 

Aranesp (darbepoetin alfa)


Amgen, the manufacturers of Epogen, also make another type of ESA called Aranesp (darbepoetin alfa). This is slightly different to the other ESAs (Epogen, Procrit, Eprex and NeoRecormon, all recombinant human erythropoietins or rhEpo), in that it is an erythropoiesis stimulating protein which contains five N-linked oligosaccharide (carbohydrate) chains rather than three. This is supposed to give it greater metabolic stability, and may be why it is less likely to cause the antibody reaction.

 

Darbepoetin alfa: a new therapy for the management of anaemia associated with chronic kidney disease (2002) Lindberg J Expert Opinion on Biological Therapy 2(8) pp977-84 discusses the use of darbepoetin alfa in human patients.

 

See below for the dosing protocol for Aranesp and how to obtain it at a reasonable cost.

 


Which Erythropoiesis Stimulating Agent To Choose


The problem with the use of any human ESA in cats is that a small percentage of cats develop an antibody reaction to the treatment. This is discussed below and is not as gruesome as it sounds, but obviously it is something you want to avoid if at all possible.

 

Epogen and Procrit (which is the same treatment with a different name) have been used in CKD cats in the USA for many years. Epogen was the subject of a clinical trial, Use of recombinant human erythropoietin for management of anaemia in dogs and cats with renal failure (1998) Cowgill LD, James KM, Levy JK, Egrie JC, Browne JK, Miller A, Lobinger R Journal of the American Veterinary Medical Association 212 pp521-8), in which 30% of cats developed the antibody reaction.

 

Eprex has been used in CKD cats in the UK for many years - I myself used it for Thomas in 1999 with no problems. Erythropoietin-associated PRCA: still an unsolved mystery (2006) Schellekens H, Jiskoot W Journal of Immunotoxicology 3(3) pp123-130 explains that the currently available HSA-free form of Eprex, which contains polysorbate 80 instead of albumin in order to comply with European regulations, had a higher antibody reaction rate.

 

I am not aware of any research into the use of NeoRecormon in cats, but my UK vet now uses it routinely for CKD cats. I think if I had an anaemic cat, I would probably favour it over Eprex these days.

 

Aranesp (darbepoetin alfa) is becoming increasingly popular for use in cats because it appears less likely to cause the antibody reaction. In 2005 a number of US veterinary schools (including North Carolina State University, University of Penn, Animal Medical Center in New York, University of California at Davis, and the University of California Veterinary Medical Center (UCVMC)) began using Aranesp on an informal basis. The last four mentioned institutions hope to publish the results of their experiences in the next few years. University of Penn ran its own trial in 2010, and hopefully the results of that study will be published in due course.

 

Aranesp has been used on approximately 50-60 cats at UCVMC, with favourable results. As a result, UCVMC now tends to use Aranesp as a first line treatment for most cats (except when they expect the need for an ESA to be short-lived because the cat is an acute case, in which case they may use Epogen instead since it may show a quicker response time). The Animal Medical Center in NYC also uses Aranesp as a first line treatment, and has found the antibody rate to be around 10%. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 discusses AMC's experiences with Aranesp. 

 

There are two formulations of Aranesp, one containing human albumin, and one with no albumin known as HSA-free. As mentioned above, the HSA-free form of Eprex had a higher antibody reaction rate. I do not know if this is also likely to be true for Aranesp but it is a possibility. However, some vets feel that ESAs containing albumin may also carry an increased risk of an adverse reaction, since the albumin is a human product. It now appears that the only version which is widely available in the USA is the albumin free (HSA-free) version, because humans apparently had a lower reaction to this, so in practice this is probably what you will be offered. I would not worry too much about this.

 

Another factor to consider is which product your vet is comfortable using. Some vets have never used ESAs, in which case it will be a learning curve for both of you. But if your vet has a lot of experience using, say, Epogen, you might feel more comfortable using that.

 

Overall, Aranesp is probably the best choice, certainly from the antibody reaction perspective, and is the treatment of choice at major US vet schools. There are a few possible downsides to be aware of:

  1. It costs a lot more than Epogen or Eprex. It needs to be given less frequently, so the cost should even out over time, but the initial outlay will be much higher, which is a concern for many people.

  2. It may take longer to start taking effect. This can be a problem if your cat's anaemia is particularly severe and you want to start making a difference as quickly as you can.

  3. It can be hard to work out the best dose for an individual cat. Some cats respond too well to Aranesp, which carries risks too.

I think overall Aranesp is the best choice and is what I would choose to use myself. However, if your cat has critically severe anaemia, or if you can obtain one of the other ESAs more quickly, then I would consider using that instead.

 

If you have already started another ESA but would like to switch to Aranesp, read how to do this here.

 


Treatment with Erythropoiesis Stimulating Agents



Obtaining ESAs At Reasonable Cost


 

Some vets think ESAs costs hundreds of dollars, and therefore may not bother to prescribe them. However, it is usually possible to obtain these products for just a few dollars (or pounds) a dose if you know where to look.

USA


 

Aranesp (darbepoetin alfa) - USA


Aranesp is more expensive than Epogen. It is sold as a single use human medication but the single use sizes are routinely used for multiple doses in veterinary medicine.

 

You need the 25mcg vial size which costs around US$150. This size vial contains approximately 6-10 feline doses, depending upon the size of your cat and which dosing regimen you use. However, since it does not need to be administered as frequently as Epogen, the cost should work out about the same overall. You will need a prescription from your vet.

 

You will usually also need U100 insulin 0.3 or O.5cc syringes which you use to draw the Aranesp from the vial in cat-sized doses. Brico Medical Supplies sells 100 Terumo syringes for around US$15 (you will need a prescription). You can also obtain insulin syringes from your local pharmacy. The Obtaining Supplies Cheaply section has more information on sources. 

 

It is usually easier to obtain price quotations if you have the NDC reference numbers for the products you are interested in. The NDC reference number for a single vial of Aranesp is NDC 55513-002-01. For a pack of four vials of Aranesp it is NDC 55513-002-04.

 

Buying Aranesp Online


It is often cheaper to buy Aranesp online. Unfortunately, some online retailers insist you buy at least four vials, which cost over US$600. However, CVS and Safeway may be prepared to sell one vial at a time for around US$160 - 180. Wal-Mart Specialty Pharmacy will definitely sell one vial at a time (see below).

 

You need Aranesp to be kept cold, so overnight shipping is best.

 

Wal-Mart Specialty Pharmacy

Walmart Specialty Pharmacy is your best bet for buying Aranesp online these days. It sells Aranesp for around US$160 per 25mcg vial including overnight refrigerated shipping. The website does not show prices so this is the approximate price but for reference, a member of Tanya’s Support Group paid US$158.93 in May 2012.

 

Note: this is Wal-Mart Specialty Pharmacy, which deals with complex therapies such as ESAs. You must use the link given above or the dedicated phone number (1-877-453-4566) to get these prices, which are not available at the standard online Wal-Mart pharmacy, and are unlikely to be available at your local Wal-Mart Pharmacy.

 

The only real downside is that it can take around a week to complete the registration process the first time you order. Wal-Mart will contact you to ask for your preferred delivery date, so you can be sure you are there to receive it.

 

Buying Aranesp Locally


If you do not want to order online, or if you need it urgently, some local pharmacies in the USA can order Aranesp with overnight delivery for around US$160 per 25 mcg vial. One person was initially quoted US$190 by her local CVS for one vial of Aranesp in July 2011 but was able to negotiate this down to US$156. Hospital pharmacies often have Aranesp in stock and may well be prepared to sell it to you with a prescription. You will also need syringes for you to draw the Aranesp into in cat-sized doses.

 

You can also look into using discount cards. If you have an AAA Travel Card, I understand that you may be able to use this to obtain discounts at some pharmacies.

 

Some members of my support group have printed out the free Pet Medication Card and have successfully used it to obtain discounts on some products (not Aranesp to date) at some pharmacies. Group members have not received any spam as a result of using the card, though many choose to use an inaccurate e-mail address to be on the safe side. Pet Med Saver Card and the RX Free Card also offer discounts, but I don't know anybody who has used them as yet.

 

Walgreens

If you want to use your local branch of Walgreens, joining their prescription club is a way to ensure you get a good price. The procedure is as follows:

 

1.    Visit Walgreens. You have to use this link - just going to the Walgreens website and searching will not work.

 

2.    Type Aranesp into the box (you will need to allow cookies), then click search. Click on Aranesp 25mcg/ml vl albumin free. The default is to show you a price for 16 vials, but click on the dropdown menu to see other options. One vial costs US$152.43 (September 2013).

 

3.    Print the page displaying the prices and take it to your local Walgreens along with your cat's prescription.

 

4.    Apply for your cat to join the Walgreens discount scheme, the Prescription Savings Club. This costs US$35 a year for family membership, which includes cats, or US$20 a year for an individual (i.e. your cat).

 

5.    Ask the pharmacist to order the Aranesp for you at or near the price on the page you have printed (some branches may occasionally sell it for less).

 

6.    Wait for the Aranesp to arrive (it should only take about a day) and go and collect it.

 

Epogen or Procrit - USA


In the USA most people use the 2,000 iu strength of Epogen. This is a single use human medication but is routinely used in veterinary medicine for multiple doses. You do not want the 10,000 iu and higher strengths, because it is too hard to obtain cat-sized doses from these.

 

A 2,000 iu strength vial will cost around US28-$36, and depending upon your cat's weight this would usually be enough for 4-8 doses.

 

You will usually also need U100 insulin 0.3 or O.5cc syringes which you use to draw the Epogen from the vial in cat-sized doses. Brico Medical Supplies sells 100 Terumo syringes for around US$15 (you will need a prescription). You can also obtain insulin syringes from your local pharmacy. The Obtaining Supplies Cheaply page has more information on sources. 

 

Most people obtain their Epogen from an online pharmacy (with a prescription), although you have to be very careful about it being refrigerated during shipping. 

 

Buying Epogen or Procrit Online


 

Wal-Mart Specialty Pharmacy

Walmart Specialty Pharmacy sells Epogen for around US$30 per 2,000 iu vial. The website does not show prices so this is the approximate price but a member of Tanya’s Support Group was quoted US$30 in September 2011. Another member paid US$98.17 in July 2011 for three vials of Epogen, syringes, needles, a sharps container and overnight shipping:

 

Note: this is Wal-Mart Specialty Pharmacy, which deals with complex therapies such as ESAs. You must use the link above or the dedicated phone number (1-877-453-4566) to get these prices, which are not available at the standard online Wal-Mart pharmacy and are unlikely to be available at your local Wal-Mart Pharmacy.

 

The only downside is that it can take a few days to complete the registration process the first time you order. Wal-Mart will contact you to ask for your preferred delivery date, so you can be sure you are there to receive it:

 

Walgreens

Walgreen's sells one vial of the 2,000iu strength for around US$33, or three vials for a little less per vial). The website does not currently show prices so this is the approximate price based on feedback I have received.

 

Walgreen's also sells six of the 2,000iu strength of Procrit (same drug as Epogen) for around US200.

 

Family Meds

Family Meds sells six vials of the 2,000iu strength of Procrit (same drug as Epogen) for US$248.11, which works out at US$41.35 a vial.

 

Buying Epogen or Procrit Locally 


If you do not want to order online, some local pharmacies in the USA, such as Walgreens, can order Epogen with overnight delivery for around US$30-35 per 2,000iu vial. Hospital pharmacies often have Epogen in stock and may well be prepared to sell it to you with a prescription.

 

You can also look into using discount cards. If you have an AAA Travel Card, I understand that you may be able to use this to obtain discounts at some pharmacies.

 

Some members of my support group have printed out the free Pet Medication Card and have successfully used it to obtain discounts at some pharmacies. Group members have not received any spam as a result of using the card, though many choose to use an inaccurate e-mail address to be on the safe side.  Pet Med Saver Card and the RX Free Card also offer discounts, but I don't know anybody who has used them as yet.

 

Walgreens

If you want to use your local branch of Walgreens, joining their prescription club is a way to ensure you get a good price. The procedure is as follows:

 

1.    Visit Walgreens. You have to use this link - just going to the Walgreens website and searching will not work.

 

2.    Type Epogen into the box (you will need to allow cookies), then click search. Click on Epogen 2,000 u/ml 1ml sdv vials. The default is to show you a price for 16 vials, but click on the dropdown menu to see other options. One vial costs US$32.99, and three vials cost US$90.97 (July 2012).

 

3.    Print the page displaying the prices and take it to your local Walgreens along with your cat's prescription.

 

4.    Apply for your cat to join the Walgreens discount scheme, the Prescription Savings Club. This costs US$35 a year for family membership, which includes cats, or US$20 a year for an individual (i.e. your cat).

 

5.    Ask the pharmacist to order the Epogen for you at or near the price on the page you have printed (some branches may occasionally sell it for less).

 

6.    Wait for the Epogen to arrive (it should only take about a day) and go and collect it.

 

UK


Unfortunately UK vets are now allowed to charge to write you a prescription to use elsewhere. My vet charges £12.50. If your vet does this, make sure your prescription is a repeat one so you don't have to pay for a new prescription every month.

 

Aranesp - UK


Aranesp is more expensive than Epogen. It is sold as a single use human medication but is routinely used in veterinary medicine for multiple doses. You need the 20mcg or 25mcg vial size. This size vial contains approximately feline 4-10 doses, depending upon the size of your cat and which dosing regimen you use. However, since it does not need to be administered as frequently as Epogen, the cost should work out about the same overall. You will need a prescription from your vet.

 

Pharmplex Direct sells a 20mcg prefilled syringe for 37.40 plus VAT and shipping. Other sizes are available. Check with your vet whether this syringe formulation is suitable.

 

One member of Tanya's CKD Support Group bought Aranesp from her local chemist for £105 for four vials, whilst another was able to buy six vials for £141 from her vet, which included monthly iron injections.

 

Your vet should also be able to order Aranesp for you.

 

Eprex - UK


This is a single use human medication but is routinely used in veterinary medicine for multiple doses. Eprex is available in various strengths but you do not want the 10,000iu and higher strengths, because it is too hard to obtain cat-sized doses from these.

 

You will usually be offered the 1,000iu strength, which confusingly is the same as the 2,000iu strength, but half the amount. Obviously, if you are using a lower strength, you need to give more of it. Your vet should be able to advise you on which strength to buy.

 

If your vet doesn't have it in stock, Eprex is available from chemists, although you will need a prescription from your vet, and the chemist may have to order it in for you (usually it can be delivered in a day or two). Back in 2000 I bought mine from Boots. It costs around £100 for six 1000 iu syringes, which is the equivalent of 12-24 treatments for most cats. In April 2011 Boots gave me a quote for 12 vials of 1000iu/0.5mL Eprex of £107.51, but needed five working days to get it.  Lloyds Pharmacy told me they could only get the 2000 strength, for around £100 for six vials, but didn't know the timeframe. The best thing to do is to call pharmacies in your neighbourhood to check prices and delivery timeframes. One lady wrote to tell me that she was able to obtain Eprex very quickly from her local hospital pharmacy, with a prescription from her vet, of course.

 

When we used Eprex, we did not need insulin syringes; instead we used the syringe and needle in which the Eprex came, giving half the vial each time. However, I am told that these days the 1,000 iu strength Eprex comes with safety syringes, which only work once. Therefore, if you want to re-use the vial, you have to transfer the contents into a sterile container, which is not exactly easy. The usual method seems to be to transfer the contents to an empty sterile vial, and measure it from there with a small insulin syringe. Unfortunately this often means you end up losing some of the Eprex, but it still works out cheaper than only using a vial once.

 

NeoRecormon - UK


My vet's wholesaler (Dunlops) can get this for them quite quickly, so this might be the quickest way to obtain it. In November 2011, one member of my support group paid £120 for six vials.

 

If your vet can't help, you would have to call around your local pharmacies as outlined above for Eprex.

 

Canada


 

Aranesp- Canada


Aranesp is more expensive than Epogen. It is sold as a single use human medication but is routinely used in veterinary medicine for multiple doses. You need the 20mcg or the 25mcg vial size. This size vial contains approximately feline 4-10 doses, depending upon the size of your cat and which dosing regimen you use. However, since it does not need a prescription from your vet.

 

Wal-Mart in Canada sells Aranesp. In November 2008 one person was quoted CA$133 for four vials of the 25 mcg 0.4ml.

 

Benefit RX sells Aranesp for US$285.73 for four syringes of the 20mcg size. I do not know anybody who has used them yet.

 

You could also ask your vet for a price.

 

Eprex- Canada


This is a single use human medication but is routinely used in veterinary medicine for multiple doses. In Canada, Eprex is available in various strengths but you do not want the 10,000 iu and higher strengths, because it is too hard to obtain cat-sized doses from these.

 

You will usually be offered the 1,000 iu strength, which confusingly is the same as the 2,000iu strength, but half the amount. Obviously, if you are using a lower strength, you need to give more of it. Your vet should be able to advise you on which strength to buy.

 

When we used Eprex, we did not need insulin syringes; instead we used the syringe and needle in which the Eprex came, giving half the vial each time. However, I am told that these days the 1,000 iu strength Eprex comes with safety syringes, which only work once. Therefore, if you want to re-use the vial, you have to transfer the contents into a sterile container, which is not exactly easy. The usual method seems to be to transfer the contents to an empty sterile vial, and measure it from there with a small insulin syringe. Unfortunately this often means you end up losing some of the Eprex, but it still works out cheaper than only using a vial once.

  • Eprex should also be available from local pharmacies, particularly hospital pharmacies. In November 2011, one person in the Toronto area was able to obtain six vials 1000 iu strength Eprex from her local pharmacy for CAN$119.

Australia and New Zealand


Although both Eprex and Aranesp are approved for human use in these countries, unfortunately it can be hard to obtain human erythropoietin in practice. This dates back to the Sydney Olympics, when the use of ESAs was severely restricted in order to make it harder for athletes to abuse the medication.

 

Aranesp - Australia


Aranesp is supplied in Australia by Amgen Australia Pty Ltd Level 7, 123 Epping Road, North Ryde. NSW 2113 Tel (02) 9870 1333.

 

Eprex- Australia


Your best bet is probably a hospital pharmacy, with a prescription from your vet.

 


ESA Dosage and Usage Guidelines


 

Here are the basic guidelines to help you use your chosen ESA as safely and effectively as possible.

How to Give ESAs


These treatments are administered by way of subcutaneous injection, so most people give the ESA to their cat themselves at home. I used to give Thomas his ESA shot after his sub-Q fluids, a short distance away from the sub-Q shot. ESAs may sting, although Thomas did not react too badly. You will still have to visit the vet at regular intervals initially (once a week), in order to monitor PCV or HCT levels and blood pressure; but once the cat is on a maintenance dose, less frequent checks are required (every 4-6 weeks).

 

These drugs contain no preservatives, so MUST be kept in the refrigerator in between treatments, but since the vials should not be shaken, do not keep them in the fridge door. It is fine to leave the vial out at room temperature for 20-30 minutes before administering it so it is not too cold when you inject your cat.

 

You should not shake the vial, though it is acceptable to roll it gently in your hand to warm it a little before giving it to your cat.

 

Some pharmacists tell people they can only use a vial once and then must throw it away; whilst this is true of human patients, it is standard to re-use vials for cats, and I am not aware of any problems arising from doing so, as long as the vial is not past its "use by" date.

 

It is a wise idea to give any anaemic cat B vitamins.

 

When you start giving an ESA, the cat's body will try to produce a lot of red blood cells, but it needs sufficient quantities of iron in order to complete the process. It is therefore often recommended to use an iron supplement as well as the ESA in order to ensure that your cat has all the necessary building blocks in place to enable the ESA to do its work. However, iron can be constipating or cause stomach upsets, plus you may not need to give as much iron as you would give if you were trying to correct a fullblown iron deficiency, so some people find simply feeding a little liver (one or two tablespoons, once or twice a week) provides sufficient iron with less risk of constipation, and most cats seem to like the taste. You should not give liver too often or in large quantities because it contains very high levels of Vitamin A, but the above dosage should be safe, though of course you should discuss this with your vet. The Animal Medical Center in NYC prefers to use iron dextran injected intramuscularly, and recommends a dose of 50mg per cat once a month.

 

Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 has information about when and how to supplement iron when using ESAs.

Use of erythropoietin and calcitriol for chronic renal failure in dogs and cats (2005) Sanderson S Presentation to the World Small Animal Veterinary Association World Congress explains more about when and how to supplement iron when using ESAs.

 

What to Expect When Using ESAs


Speed and Nature of Response


It usually takes around 1-2 weeks for the medication to show an effect, with PCV or HCT usually rising around 2% a week. When I say by 2%, I mean, for example, a rise from 15% to 17%, not 2% of the original  level (15% in this example). Your vet should check PCV or HCT and blood pressure a week after starting treatment, and again a week later. Regular checks should then continue until the level is stable. If you are giving the ESA weekly, these checks may be performed weekly. If you are giving the ESA less frequently, it is probably still wise to check PCV or HCT and blood pressure weekly if you can, at least in the first month.

 

Some cats will show an abrupt increase in PCV in the first week of use, perhaps as much as a 10% increase. This is more likely to happen in cats with less severe anaemia (and in fact some of them perhaps are starting the medication a little prematurely, before PCV or HCT is below 20%), and/or in cats with less severe CKD (creatinine under 450 international, 5 in US values) whose kidneys may still be able to make a little erythropoietin on their own. One analogy used is that if a fire has not gone out completely, it is easier to fire it up again than if it has virtually gone out. An abrupt increase of this nature in the first week is probably not cause for concern as long as your cat's blood pressure is under control, but if PCV or HCT continues to rise faster than 4% in two weeks, you should ask your vet about reducing the amount given, because rises in excess of this level have been associated with an increased risk of hypertension and stroke in human patients.

 

Conversely, some cats' PCV or HCT may continue to fall in the first couple of weeks of use of an ESA. This is quite common if your cat is dehydrated when you first begin the treatment. As mentioned in Hemoglobin and Hematocrit (1990) Billett HH in Clinical methods: the history, physical and laboratory examinations, Third Edition, Eds. Walker HK, Hall WD & Hurst JW chapter 151, dehydration inflates the PCV or HCT value, so if your cat is dehydrated when PCV or HCT is tested, the value will appear higher than it actually is. For example, if your cat has a  PCV level of, say, 20%, but is dehydrated when the test is run, the level may appear lower (say, 18%) once the dehydration has been brought under control. The exact fall would depend upon the level of dehydration at the first check.

 

If your cat is not dehydrated but PCV has fallen, it may simply be that the medication needs a bit more time to kick in. I know when this happens, some vets immediately say it is the antibody reaction, but that is unlikely because the usual timeframe for the antibody reaction is after 4-5 months of use. Managing anemia in patients with chronic kidney disease (2011) Chalhoub S, Langston CE Veterinary Medicine May 2011 has a helpful table (in a pop up window halfway down the page) entitled "algorithm to troubleshoot persistent anemia (below PCV range) while using darbepoetin" which your vet can use to as a checklist if PCV or HCT is not rising as you would expect. Try not to panic. If you keep going, double check you are giving the correct dosage, and your vet checks for other causes of anaemia, such as gastro-intestinal bleeding or infection, and ensures you are giving B vitamins and iron, you should start to see an improvement after 2-3 weeks. In the meantime, depending upon how severe your cat's anaemia is, you may have to consider a blood transfusion to tide your cat over until the ESA begins to work.

 

Very occasionally, it is possible to stop giving ESAs completely. This might be the case, for example, with a cat who has acute kidney injury rather than CKD and whose anaemia improves as the kidneys start functioning again. However, in a cat with CKD it is unlikely that you will be able to stop the ESA completely, and stopping and starting is not recommended (see below).

 

Monitoring PCV or HCT Levels


During the first few weeks of using ESAs, PCV or HCT levels should be monitored carefully. Initially it is best to check weekly, and since there is a risk of hypertension when using ESAs, blood pressure should be checked at the same time

 

Always check PCV or HCT before administering the next dose of the ESA, because you only want a rise of around 2% a week (if it rises faster, it increases the risk of hypertension and other problems). If it is rising faster than this, apart from in the first week (see above), then speak to your vet about reducing the dose you are using.

 

Target PCV or HCT Level


How high should the PCV or HCT be? This is a tricky question these days, to which there is no simple answer.

 

When I first used an ESA in 1999, it was common to aim for a target PCV or HCT of around 35% for cats on an ESA. This was roughly in the middle of most laboratory ranges, and meant the cat was definitely no longer anaemic (since many laboratory ranges start at 29%, while others start at 24%). Going above 35% was not recommended for cats because higher levels increase the chances of thrombosis and associated heart problems; but very few cats I heard about seemed to have a problem with a PCV or HCT of 35%. This target also tied in with the general recommendations for humans using ESAs.

 

For Aranesp, there is currently a wide range of recommendations:

In June 2011 the FDA recommended that a goal for PCV or HCT levels should no longer be set for human patients on ESAs (see below). Instead, it states that the lowest dose sufficient to "reduce the need" for blood transfusions should be used.

 

It is possible that the various vet schools may revise the higher targets for cats mentioned above in light of the FDA recommendations for human ESA patients; but with cats there are other factors to consider. Let's consider the Animal Medical Center recommendation of a PCV or HCT of 25%. With some laboratories, this would actually mean that the cat was still anaemic or barely out of anaemic range (the HCT range for some labs starts at 24%, but at 29% for others), I believe this would be the case at AMC itself - when my cat had blood tested there, the lab range began at 29%, although it is possible that the range has changed since then. If your cat remains in the anaemic range, s/he might still be experiencing the effects of anaemia.

 

A low target like this also gives you little room for manoeuvre should your cat suddenly become more anaemic (perhaps because of sudden blood loss or infection). It is relatively easy to arrange a blood transfusion for a human whose anaemia suddenly worsens, with blood banks easily accessible almost everywhere, but it is a lot harder (though not always impossible) for a cat.

 

Therefore, in practice I think "reducing the need" for blood transfusions would not be the best choice for most cats, especially since there is a risk of an antibody reaction to repeated blood transfusions in cats. Avoiding the need for transfusions seems more appropriate, especially for those who do not live in a big city with prompt access to blood transfusions; and even those who do live in such a place might wish to avoid the costs and inconvenience and worry of a transfusion.

 

You might decide not to aim for an exact target, but to monitor your cat and alter your ESA dosing once the HCT or PCV is approaching normal range and at a stable level, as long as the symptoms of anaemia have gone. If your cat is still showing signs of anaemia, however, you may wish to cautiously aim for a higher PCV or HCT level. Generally speaking, a range of around 25-30%, depending upon your laboratory's reference levels (25% if your laboratory's range starts at 24%, or 30% if your laboratory's range starts at 29%), might be reasonable, but aiming for 30-35%, as I have seen many people do successfully, might also be appropriate, at least if your laboratory's range begins at 29%.

 

It's not easy, is it? When we made the decision to use an ESA for Thomas, we decided to make sure he was no longer anaemic. Despite all the increased knowledge about the use of ESAs in cats today, I think I personally would still have the same goal today, in which case I would aim for an HCT in the 30-35% range, but monitor blood pressure carefully. Discuss with your vet what would be most appropriate for your cat.

 

Frequency of Dosing


Once the PCV or HCT level is close to your goal, the dose frequency is reduced to whatever level is necessary to maintain the PCV or HCT at the desired level.

 

With Aranesp, it is usual to reduce the frequency from once a week to once every 2-3 weeks. Apparently many cats only need a maintenance dose every 3-4 weeks. 

 

With Epogen, Procrit, Eprex or NeoRecormon, many vets reduce dosing frequency to twice a week initially, but may then reduce to once a week or eventually to once every 10-14 days. You may also be able to reduce the amount given to as low as 75 units per kg bodyweight. If the anaemia begins to recur at these lower levels or frequencies, you will usually need to increase the amount and/or frequency of the injections (though you should also check for other possible causes, such as infection or gastro-intestinal bleeding).

 

There is a timelag of approximately 1-2 weeks between giving the ESA and seeing its effects on PCV or HCT, so you need to bear this in mind when adjusting dosages because PCV or HCT levels will continue rising for some time after each dose.

 

Once a cat has reached a stable PCV or HCT on an ESA, I would recommend still checking PCV or HCT every 4-6 weeks in order to ensure that your cat is not developing the antibody reaction, and I would also get blood pressure checked at the same time.

 

How to Check PCV or HCT


When testing PCV or HCT, it is not necessary to draw a lot of blood (which could worsen the anaemia) - a tiny drop taken from the ear may be sufficient. Veterinary Partner has a description of how this is done in diabetic cats, as does Sugar Cats. Some machines do need more blood than this, but it's worth asking your vet if this method could be used because in most cases it can.

 

Several members of Tanya's CKD Support Group use a home haematocrit tester. It is expensive at US$150 for the machine (the total cost including accessories and shipping costs is around US$195) but over time it can pay for itself, and it is certainly less stress than regular trips to the vet. If you wish to purchase one, try this eBay link - he will ship worldwide. If the link is broken (it changes regularly) the e-mail address at the bottom of this link is still valid, so make contact that way. If you do buy a home tester, I would recommend checking your first few readings against readings at the vet's, to make sure you are doing it properly and to reassure your vet that you are obtaining accurate readings at home. I'd also advise caution if you are dealing with severe anaemia (PCV below 18%), because when PCV is so low, every percentage point matters, plus vet visits give your vet the opportunity to check blood pressure as well as checking PCV. If you do buy one of these machines, please check its readings against those from your vet's equipment..

 

One possible compromise would be what one member of Tanya's CKD Support Group used to do. He would obtain the blood from his cat's ear at home as outlined above, but then take the sample to his vet for analysis. This saved his cat the stress of the vet trip, but still gave an accurate result.

 

Risks and Side Effects of ESAs


The antibody reaction is discussed below, but that is not normally seen (if it occurs at all) until the cat has been on an ESA for 4-5 months. This section focuses on the risks to be aware of as soon as you start using an ESA.

 

Most CKD cats do not seem to have problems when using ESAs, but possible side effects include hair loss, diarrhoea and very rarely seizures.

 

The major concern when using an ESA is hypertension, which in the worst case may cause heart problems or a stroke. The use of erythropoietin (2003) Langston CE, Reine NJ & Kittrell D Veterinary Clinics of North America Small Animal Practice 33(6) pp1245-1260 found that 40-50% of cats on ESAs develop hypertension, so blood pressure should always be monitored while your cat is on an ESA, particularly when you first begin treatment.

 

Since CKD cats are prone to hypertension anyway, ideally you should have started monitoring blood pressure as soon as your cat was diagnosed with CKD; but if you have not been doing this, do try to ensure that blood pressure is monitored once you begin the ESA. If your cat's blood pressure rises to an unacceptable level (see hypertension for information on target blood pressure levels) and your cat is not yet on blood pressure medication, you will probably need to start it. If you are already giving blood pressure medication, you may need to increase the dose. You may also need to decrease the amount and/or frequency of the ESA, at least until blood pressure is under control. Be guided by your vet as to the best course of action in your cat's case.

 

There is some debate as to whether ACE inhibitors may exacerbate anaemia and/or induce some resistance to the use of human erythropoietin in humans. The role of ACE inhibitors and angiotensin II receptor blockers in the response to epoetin (1999) MacDougall IC Nephrology Dialysis Transplantation 14(8) pp1836-1841 reports on the evidence for and against this concern in humans. If your cat is on both an ESA and an ACE inhibitor such as Fortekor, I would discuss this with your vet.

 


Dosage Guidelines


 

Dosage and Usage Guidelines for Aranesp (darbepoetin alfa)


 

Please also read the general information on how to give ESAs and how to monitor things above.

 

Aranesp Dosage


There are a number of possible dosing protocols for Aranesp, so you must be guided by your vet as to which to use for your cat. Remember, Aranesp is given less frequently than Epogen, usually only once a week to start with.

  • The dose for human patients on Aranesp is 0.45mcg per kg (a kg is 2.2 lb) body weight, given subcutaneously. Plumb's Veterinary Drug Handbook (7th edition) (2011) recommends this dose for cats. This would mean that a 4.5kg (10 lb) cat would receive a dose of just over 2mcg (see table below).

  • Dr S DiBartola of Ohio State University College of Veterinary Medicine recommends a lower dose of  0.25 - 0.5 mcg per kg (a kg is 2.2 lb) body weight, given subcutaneously.

  • The current dosage being used by some US veterinary schools, including the University of California at Davis, is to give a single dose subcutaneously of 6.25 mcg each week, regardless of the cat's weight. One vet school gives 6.25 mcg along with iron in the first week, but then spaces the Aranesp out as far as possible, usually giving it once every 2-4 weeks. I have heard from a number of people who found their cat's PCV increased too quickly on this dose.

  • The Animal Medical Center in NYC uses a dose of 1 mcg per kg bodyweight once weekly, so, for example, a 10lb or 4.5 kg cat would receive 4.5 mcg each week. Anemia of renal disease: what it is, what to do and what's new (2011) Chalhoub S, Langston C & Eatroff A Journal of Feline Medicine & Surgery 13(9) pp629-40 states that this dosage is used because 62% of cats in their database responded to this dose, whereas only 12% responded to a dose of 0.45 mcg/kg weekly. Once target PCV is reached, the frequency is reduced as appropriate for each cat.

  • I have also heard from a couple of people who gave their cats 5 mcg subcutaneously each week. Again, one of these cats had a PCV that was increasing rather quickly.

Because Aranesp is given less frequently than rhEpo, it also takes longer to take effect. Therefore, if your cat has very severe anaemia before starting Aranesp, you may need to consider a blood transfusion to tide your cat over until the Aranesp begins to take effect. 

 

Overall it appears that many cats respond well to Aranesp, and in some cases their PCV rises too quickly. If your cat is not critically ill with anaemia (e.g. the PCV is over 14%), I therefore recommend starting with a low dose, particularly if your cat is small. Always check PCV before you give the next shot in case your cat is particularly responsive.

 

Calculating Your Cat's Dosage of Aranesp


 

If Dosage of 0.45 mcg per KG in Weight is Prescribed

 

8 lb (3.65kg) Cat

10 lb (4.5kg) Cat

12 lb (5.45kg) Cat

Aranesp Dosage

1.64mcg

2.03mcg 2.45mcg

 

If your cat's PCV rises too quickly (more than a 2% increase in PCV or HCT per week), ask your vet about reducing the dose or giving the Aranesp less frequently, because it is important to adapt the dosing schedule to what works for your cat.

 

One person whose cat was being treated at a vet school told me that one cat's HCT did not improve when the Aranesp was put into a vial and dosed from there. However, when they emptied the pre-filled Aranesp syringe into an insulin syringe and dosed directly from there, the cat's HCT started rising.  So it may be safer to dose in this manner.

 

Switching from Another ESA to Aranesp


Some people decide to switch from Epogen, Procrit or Eprex to Aranesp because they wish to reduce the risk of the antibody reaction. This section explains how do to this. However, if you wish to switch from another ESA to Aranesp because you think your cat has developed the antibody reaction to the other ESA, please read here.

 

Be guided by your vet, but for reference, Plumb's Veterinary Drug Handbook (7th edition) (2011) states that you can convert the dosage by dividing the total weekly number of Epogen or Procrit units by 200. This will then give you the equivalent weekly dose of Aranesp.

 

For example, if a cat receives 450 units of Epogen three times a week, this means the weekly total is 1350. Divide the 1350 by 200 and you get 6.75, so the cat would receive 6.75mcg of Aranesp once a week.

 

Dosage and Usage Guidelines for Epogen, Procrit or Eprex


 

Commonly Used Dosages for Epogen, Procrit or Eprex


Plumb's Veterinary Drug Handbook (6th edition) (2008) by Donald C Plumb suggests using 100 units of Epogen, Procrit or Eprex per kg (2.2lbs) of bodyweight, given subcutaneously three times a week, until you begin to approach the target PCV level (usually around 35% but see above). 

 

Some cats may require higher doses initially, particularly cats with severe anaemia. For cats whose PCV or HCT is below 14%, Plumb's suggests using up to 145 units per kg (2.2lbs) of bodyweight, also given subcutaneously three times a week. You may also wish to discuss this dosage level with your vet if your cat does not appear to respond to the treatment at the initial starting dose outlined above.

 

However, a lower dose of 48.4 units per kg (2.2lbs) of cat, subcutaneously three times a week, may be advisable if the cat has hypertension (high blood pressure) before starting Epogen, Procrit or Eprex, or if hypertension appears after starting.

 

When giving the ESA three times a week, I would simply give it every other day with one day left over e.g. Mon/Wed/Fri or Tue/Thur/Sat.

 

Calculating Your Cat's Dosage of Epogen, Procrit or Eprex


The exact amount to be given depends upon the strength which you are using. These medications are sold in varying strengths, but the larger sizes (10,000iu/mL upwards) are impossible to give in cat-sized amounts, so try to use nothing larger than the 3000iu/mL strength. Most people use the 2000iu/mL strength. If for some reason you do end up using the 10,000 strength and above, be aware that the medication may lose its potency before you get a chance to finish the vial. This can lead you to incorrectly suspect that your cat is developing the antibody reaction.

 

Calculating how much to use can be very confusing! Normally you will be told how many units to give, based on your cat's weight. 1 cc of the 3000iu/mL strength contains 3000 units of medication; 1 cc of the 2000iu/mL strength contains 2000 units; and so on. We used the 1000iu strength of Eprex, which (just to confuse matters) is slightly different: it contains 1000iu but in 0.5mL so it is the same strength as the 2000iu/mL although it sounds different. Whichever you use is less important than giving the correct amount.

 

If you are using Epogen or Procrit, you will probably also need syringes to give the medication. Most people use human insulin syringes. These are sold as U100 syringes, which means there are 100 units in 1 ml. They are usually available in three sizes, 1 ml (100 units), 0.5ml (50 units) or 0.3 ml (30 units), and most people use 0.5 or 0.3 ml syringes for cats (see above for sources). Unfortunately, insulin units are not the same as Epogen units so working out the dose can be confusing. As a general guide, one insulin unit is 0.01ml; so each unit on an insulin syringe is 0.01ml; but the safest thing is to ask your vet to measure out the doses for you and show you how much you need to give.

 

As you can see, the Epogen dosages below are pretty precise, but your vet will probably want to round the dose up or down so as to make it easier for you to measure it. Although the dosages refer to Epogen, they also apply to Procrit and Eprex.

 

If Dosage of 100 units per kg in Weight is Prescribed

 

8 lb (3.65kg) Cat

10 lb (4.5kg) Cat

12 lb (5.45kg) Cat

Epogen Strength

Needs

365 Units

Needs

450 Units

Needs

545 Units

1000 iu/mL*

0.1835 cc

0.225 cc

0.273 cc

2000 iu/mL*

0.1835 cc

0.225 cc

0.273 cc

3000 iu/mL

0.122 cc

0.15 cc

0.18 cc

4000 iu/mL

0.09 cc

0.1125 cc

0.137 cc

*The 1000iu strength contains 1000iu but in 0.5mL so it is the same strength as the 2000iu/mL

 

Please also read the basic usage guidelines for ESAs.

 

Dosage and Usage Guidelines for NeoRecormon


I have only heard from a few people using NeoRecormon. Most people seem to be using it in similar fashion to Epogen or Eprex, giving it three times a week  and 50-100iu per kg of body weight (usually 100iu per kg of bodyweight is used for Epogen or Eprex).

 

I did find one reference about using it, Veterinary Pharmacology, which suggests the above dose but which also recommends that PCV should increase by 1% a day for the first month (!), which seems inappropriate to me - I would recommend the more usual target  increase of 2% a week would be a more suitable goal.

 

Please also read the basic usage guidelines for ESAs.

 


Possible Problems with ESAs


 

There are two main reasons why some vets are reluctant to use ESAs.

  1. The cost: vets often mistakenly believe that it costs hundreds of dollars when in fact, depending upon your cat's size and the severity of the anaemia, it may cost as little as US$5-10 per dose (see Obtaining ESAs at Reasonable Prices).

  1. They fear possible side effects as follows:

 


The Antibody Reaction


What is the Antibody Reaction


ESAs are extremely effective drugs, but unfortunately, there is one potential major disadvantage to using them. These medications are manufactured using recombinant human DNA. As a result, some cats will eventually produce an antibody reaction because their bodies consider the ESA to be a foreign body. These antibodies then neutralise the ESA (i.e. stop it working to produce red blood cells), so the anaemia returns. In this site I refer to this as the antibody reaction, but elsewhere you may see this referred to as PRCA, which is the most extreme form of the antibody reaction.

Because of the risk of the antibody reaction, it is usually recommended that cats should not be placed on ESAs until the benefits of using them outweigh the risks. For most cats this means once their PCV has fallen to 15-19% and they are showing symptoms of anaemia, such as loss of appetite, lethargy etc. In theory, this will often not happen until the CKD is fairly well advanced with creatinine levels over 500 (US: 5.65), although this is not always the case - Thomas needed rhEpo regularly when his creatinine level was only 316 (US: 3.57), although this had been a lot higher at initial diagnosis.   

It is not known for certain how many cats go on to develop this antibody reaction because it is hard to test for this. Some sites refer to a rate of around 70% but in the only clinical trial to date on the use of an ESA in cats, Use of recombinant human erythropoietin for management of anaemia in dogs and cats with renal failure (1998) Cowgill LD, James KM, Levy JK, Egrie JC, Browne JK, Miller A & Lobinger R Journal of the American Veterinary Medical Association 212 pp521-8, the number of cats who developed the reaction to Epogen was around 30%. In Anemia of chronic kidney disease (2009) Dr CL Langston says that the rate seen at Animal Medical Center in NYC is around 21% for Epogen.

 

It appears that Aranesp may be less likely to cause the antibody reaction. There has been one suspected case of the antibody reaction in a dog at UCMVC but this was never confirmed. I haven't heard of any confirmed cases in cats as at October 2011, though they probably exist. In Anemia of chronic kidney disease (2009) Dr CL Langston says that the rate seen at Animal Medical Center in NYC is around 10% for Aranesp, but this figure includes dogs (they have had two confirmed cases in dogs) and I don't know how much of that percentage were cats.

 

In my experience over the last twelve years of monitoring a number of CKD-related online groups, the frequency of the antibody reaction in practice appears to be far lower than 25-30%, perhaps closer to 5-10%. See below for a possible explanation of this discrepancy.

 

It is impossible to predict which cats will develop the antibody reaction, although Eprex appears to carry a higher risk of the antibody reaction for humans than either Epogen or Procrit, particularly if the HSA-free form of Eprex (which contains polysorbate 80 instead of albumin, in order to comply with European requirements) is used. Erythropoietin-associated PRCA: still an unsolved mystery (2006) Schellekens H & Jiskoot W Journal of Immunotoxicology 3(3) pp123-130 has more information about this.

 

The antibody reaction does not usually occur in the first month of use, and if it is going to occur it almost always happens around 4-5 months after commencing treatment (only rarely does it happen much earlier or later than this). There is no definitive test to show that the cat has developed the antibody reaction; a bone marrow aspiration (biopsy) would provide some information, but is invasive and unlikely to be worthwhile. Pet Place explains more about bone marrow and bone marrow biopsy. Washington State University College of Veterinary Medicine has some information on how this procedure is performed. 

 

From a practical perspective, the main sign of an antibody reaction is that the cat's PCV value will steadily drop by approximately 2% a week, despite the use of adequate amounts of an ESA. Large drops in PCV in the space of a few days or a week are unlikely to be caused by the antibody reaction, and other possible causes such as gastro-intestinal bleeding should be investigated. Rapid falls may occasionally be a sign of PRCA, but this is rare.

 

Anemia of renal disease: what it is, what to do and what's new (2011) Chalhoub S, Langston C & Eatroff A Journal of Feline Medicine & Surgery 13(9) pp629-40 states that "Lack of available iron for erythropoiesis is recognised as the leading cause of treatment failure in humans on ESA therapy." If you have not been supplementing iron, therefore, you should consider this possibility before fearing the worst. See above for dosage guidelines. Even if you have been supplementing iron, a lack of iron may still be a factor because cats in the study who were receiving both an ESA and oral iron supplements still had decreased iron levels.

 

To complicate matters further, your cat may actually need more ESA than you have been giving: many vets give too small a dose in the mistaken belief that this may reduce the risk of the antibody reaction. Plus some cats simply need more ESA than others - Thomas's PCV went up and down in the first few weeks of treatment so we were very worried, but we simply gave him more of the ESA rather than less, and his PCV then rose steadily. A cat whose CKD is advancing may also need more ESA than s/he previously needed. A cat who appears not to be responding to the ESA may also need more iron. If for some reason you are using the 10,000 strength and above ESA (which is not recommended in cats), the drug may lose its potency before you get a chance to finish the vial. This can lead you to incorrectly suspect that your cat is developing the antibody reaction.

 

Other possible causes for a failure to respond to ESAs include a lack of folic acid (Vitamin B9) or Vitamin B12, infection, inflammation, cancer or  hidden blood loss (e.g. from gastro-intestinal bleeding).

 

So if PCV levels do begin to fall, you should not automatically fear the worst, but instead should consider all other possible causes of the fall. In Anemia of chronic kidney disease (2009) Langston CL says that over 75% of human patients whose anaemia does not improve on an ESA have an infection or inflammation. She states "In a retrospective study of cats, 25 per cent of patients did not reach the target haematocrit and were suspected of having infection or inflammation (unpublished data, Langston and Kittrell, 2006). Higher doses of rHuEPO do not overcome the resistance; control of the infection or inflammatory state is necessary."

 

Why the Risk of Using an ESA is Often Worth It


Whilst nobody wants their cat to experience the antibody reaction, it must be stressed that it is not as awful as it sounds. Some people think it is akin to anaphylactic shock but it is nothing like that at all!

 

What normally happens is that the PCV gradually falls at a rate of around 2% a week (any larger fall and you should search for another cause, such as gastro-intestinal bleeding), despite the cat being on an ESA. If the cat is still producing a little erythropoietin naturally, the antibodies may also neutralise the cat's own erythropoietin as well, at least for a while, and this further worsens the anemia. In the worst case, a condition called PRCA can occur.

 

But, and most importantly, even in those cats who develop the antibody reaction, the erythropoietin antibodies will not always neutralise the effects of the ESA. In other words, some cats may have the antibody reaction but you would never know it because the ESA continues to work and the cat does not become anaemic again. This may explain why it is often claimed that 30% of cats develop the antibody reaction, yet in practice on the online support groups, the percentage appears to be much lower, around 5-10%.

 

If your cat does develop the antibody reaction to an ESA, since the resulting anaemia will eventually kill the cat, the only remedy is to stop using the ESA. It takes the cat's body 3-4 months until the antibodies wear off, and during that period it is often necessary to keep the anaemia under control via blood transfusions. You cannot start using the ESA again, even after the antibodies wear off, so depending upon the level at which your cat's anaemia stabilises, you may need to use blood transfusions indefinitely. Some vet schools have been investigating using Aranesp in cats who have developed an antibody reaction to Epogen or Eprex, you can read more about this here.

 

In most cases the cat was suffering from severe anaemia, otherwise an ESA would not have been started in the first place. So in the worst case, using an ESA will have bought you an extra few months with your cat; and in the best case, using an ESA could control your cat's anaemia indefinitely. 

 

Why Stopping and Starting ESAs is a Bad Idea


Very occasionally, it is possible to stop giving ESAs completely. In fact, if your cat has acute kidney injury rather than CKD, you may not need to start them in the first place - although cats with ARF tend to have high bloodwork results generally, they often are not anaemic, or, if they are, the anaemia resolves itself naturally as the kidneys begin working again.

 

However, I have heard that some vets have a policy for every CKD cat they treat of using an ESA short-term until the anaemia is resolved, then stopping it and starting it again later when the cat has become anaemic again, in the mistaken belief that this may reduce the risk of the antibody reaction.

 

This is really not a good idea. Dr Katherine James, who participated in the Epogen trial in cats mentioned above (the trial that has many vets worried about the antibody reaction in the first place) has stated that there is no evidence either way, but she suspects that doing this might actually increase the risk of the antibody reaction occurring. She also believes that the resulting fluctuations in PCV could cause problems with blood pressure control.

 

On the most basic level, I really do not see the point of allowing a cat to become anaemic again, with all the strains on the body and effects on the cat's quality of life which that entails. Most scarily, I have heard from two people whose vets insisted on this approach and their cats died of anaemia during one of their anaemic phases. If you decide to use an ESA, I'd recommend making a commitment to using it fully in order to keep your cat free of anaemia.

 

Pure Red Cell Aplasia (PRCA)


In the worst case, the antibodies to an ESA which some cats develop may cause the cat not only to neutralise his or her own erythropoietin but also to develop a condition called pure red cell aplasia (PRCA), which also kills off existing red blood cells. In such a case, the cat develops a sudden loss of response to the ESA, the PCV or HCT level falls suddenly, and the reticulocyte count will be extremely low. The cat will often be very lethargic and short of breath.

 

Many vets believe that the antibody reaction to ESAs is identical to PRCA. They therefore fear that the chance of this happening is around 30%, and consider that any cat who suddenly becomes more anaemic despite being on an ESA must be developing PRCA.

 

I see it more as a question of degree. Whereas some cats develop the antibody reaction mildly (so the ESA keeps on working for them, see above), those cats who develop PRCA are exhibiting a reaction at the opposite end of the spectrum, which also affects their existing red blood cells. In Pure red cell aplasia clinical presentation (2009), Dr Paul Schick states that "The development of pure red cell aplasia may represent the extreme end of the spectrum of EPO-induced immunological suppression of RBC production."

 

PRCA is thought to be an autoimmune condition, and developing it as a result of using an ESA is rare - humans on ESAs have a rate of PRCA of less than 1%. Most cases in humans on ESAs occurred in people using Eprex prior to 2003, and cases tended to be concentrated within certain countries such as the UK and France, whereas Germany had hardly any. The cases that were seen coincided with a change to the formulation of Eprex. The currently available HSA-free form of Eprex, which contains polysorbate 80 instead of albumin in order to comply with European regulations, had a higher PRCA rate; and it was also thought that the way the drug was administered may have been a factor (subcutaneous administration appeared to increase the risk). Erythropoietin-associated PRCA: still an unsolved mystery (2006) Schellekens H, Jiskoot W Journal of Immunotoxicology 3(3) pp123-130 reports further on this issue. Following prescribing changes in December 2002, even though the same type of Eprex was being used, the number of human cases of PRCA fell dramatically. Epoetin-associated pure red cell aplasia: past, present and future considerations (2008) McKoy JM, Stonecash RE, Cournoyer D, Rossert J, Nissenson AR, Raisch DW, Casadevall N & Bennett CL Transfusion 48(8) pp1754-62 explains more about the numbers involved.

 

PRCA appears to be more common in cats, though it is hard to know exactly how many cats develop it because many vets do not differentiate between PRCA and the less severe form of antibody reaction. In humans, PRCA usually does not occur until the patient has been on an ESA for three months. If the same applies to cats, you should therefore be safe for the first three months of using an ESA. If your cat's PCV or HCT suddenly falls, whether during or after the first three months of use, consider other causes before fearing the worst. In Anemia of chronic kidney disease (2009) Dr CL Langston says that over 75% of human patients whose anaemia does not improve on an ESA have an infection or inflammation. She states "In a retrospective study of cats, 25 per cent of patients did not reach the target hematocrit and were suspected of having infection or inflammation (unpublished data, Langston and Kittrell, 2006). Higher doses of rHuEPO do not overcome the resistance; control of the infection or inflammatory state is necessary." Therefore, if your cat's PCV falls suddenly, you should not necessarily immediately stop the ESA but you should look for other causes of the fall such as infection, Vitamin B12 deficiency etc.

 

If, however, your cat really does develop the antibody reaction so severely that PRCA results, you must immediately stop using the ESA. You might need to arrange a blood transfusion for your cat. It takes the cat's body 8-10 months until the antibodies wear off, and during that period it is often necessary to keep the anaemia under control via regular blood transfusions. You cannot start using the ESA again, so depending upon the level at which your cat's anaemia stabilises, you may need to use blood transfusions indefinitely. Although this is a big commitment and expense, I do know of people who have done this successfully. Some vet schools have been investigating using Aranesp in cats who have developed an antibody reaction to Epogen or Eprex, you can read more about this here. It is possible that stem cell transplants may also help.

 

Please don't feel guilty if your cat develops PRCA. Your cat was most probably suffering from severe anaemia, otherwise an ESA would not have been started in the first place. So in the worst case, using an ESA will have bought you an extra few months with your cat; and in the best case, using an ESA could control your cat's anaemia indefinitely. 

 

FDA Warnings


As mentioned above, there can be other risks using ESAs, such as high blood pressure, seizures, heart problems and strokes (although controlling blood pressure does help reduce the risk of many of these issues). Various warnings relating to these concerns have been issued by the US Food & Drug Administration over the years regarding the use of ESAs in humans. The 2007 FDA warning recommended aiming for lower target haemoglobin levels than many doctors originally aimed for, because this reduced the risks of serious side effects. Previously many doctors aimed for a haemoglobin (Hb) level over 12, but the 2007 warning recommended aiming for an Hb level of between 10 and 12.

 

Targets for human ESA patients are measured in haemoglobin, but in haematocrit (HCT) or packed cell volume (PCV) for cats. To convert Hb into HCT, you multiply by approximately three. If the advice for humans was extrapolated to cats, this would have meant that your target HCT (based on the maximum Hb level of 12) should be no higher than 36. Since it had long been recommended that people aim for a conservative HCT or PCV level of no more than 35% in cats using these products, this warning did not raise any additional concerns when it was issued.

 

The 2011 FDA warning, issued in June 2011, states that humans on ESAs are considered to be at greater risk of adverse events if they target an Hb level of 11. The FDA now declines to state when humans should start ESAs or what level of Hb they should aim for, but instead recommends individualised dosing and states that the lowest dose sufficient to reduce the need for blood transfusions should be used.

 

I discuss the implications of these warnings for cats above.

 


Should I Use an ESA?


 

I know it is not easy making the decision to use an ESA, and your head is probably spinning after reading this page (I've tried to make it as clear and simple as I can, but I'm afraid it's a complicated subject). Please discuss the pros and cons with your vet before making your decision. Remember, you should not normally need to use an ESA if the cat's PCV or HCT is 20% or higher. The criteria for knowing if it is time to consider using an ESA are here.

 

If your cat does have severe CKD-related anaemia caused by a lack of erythropoietin, then to some extent there is no real decision to make, because the only real alternative to starting an ESA is to watch your cat die of anaemia. Anemia of renal disease: what it is, what to do and what's new (2011) Chalhoub S, Langston C & Eatroff A Journal of Feline Medicine & Surgery 13(9) pp629-40 discusses when to use an ESA. We decided to use an ESA for the following reasons:

  • It was quite obvious that if we did not do so, the anaemia would kill Thomas long before the CKD would (he was extremely  weak, had no appetite and was breathless).

  • We felt the odds were in our favour with at least a two to one chance that it would work for us. 

  • Even if he were to develop the antibody reaction, it should buy him 4-5 months of additional time and thus postpone having to say goodbye.

  • In the best possible scenario, once the ESA had done its work, we would never have to worry about CKD-related anaemia caused by a lack of erythropoietin again.

If you are considering the use of an ESA, don't take too long to make your decision, because if you do, your cat may die of the anaemia before the ESA has a chance to take effect (it may take up to two weeks to see an improvement after starting to use an ESA, and the anaemia should only improve gradually). If your cat has a low PCV or HCT but is acting relatively well, don't be lulled into a false sense of security. Because non-regenerative anaemia caused by CKD tends to develop and worsen gradually many cats' bodies do adapt to the anaemia, so they may not seem desperately ill but they could still suddenly hit crisis point. If necessary, a blood transfusion might help your cat through a critical period while you wait for the ESA to take effect.

 

Personally I would never let PCV fall below 15% before starting an ESA, and if my cat was showing symptoms of anaemia with a PCV of 16-19%, I would start it earlier. We began it as soon as Thomas was diagnosed following his crash, when his PCV was 18% (though it was probably lower, since he was severely dehydrated at the time - as mentioned in Hemoglobin and Hematocrit (1990) Billett HH in Clinical methods: the history, physical and laboratory examinations, Third Edition, Eds. Walker HK, Hall WD & Hurst JW chapter 151, dehydration makes PCV look higher than it really is. When he died seven months later, his anaemia was completely under control. If we had not used the ESA, he would have only managed a month at most.

 

So, to summarise:

  • at the present time there are no alternatives to ESAs for the treatment of severe CKD-related non-regenerative anaemia (milder anaemia may be treated via the methods outlined here).

  • if you do not use an ESA for severe CKD-related non-regenerative anaemia, your cat will die of anaemia.

  • the antibody reaction is rare. Even going by the worst case statistics, your cat has less than a 1 in 3 chance of developing the antibody reaction whilst on Epogen, or only a 10% chance while on Aranesp. That's a 90% chance in your favour! Based on what I've seen over twelve years of online support groups, your cat has more like a 1 in 10 to 1 in 20 chance of developing the antibody reaction.

  • if your cat does develop the antibody reaction, it will not usually be for 4-5 months, during which time your cat will have no problems at all with anaemia.

  • if the antibody reaction occurs, your cat will normally become anaemic again gradually, which simply means you will be back where you started 4-5 months earlier when you first decided to use erythropoietin.

  • if the antibody reaction occurs, you will see a fall in PCV/HCT of around 2% a week. A larger fall may indicate PRCA, but may also indicate some other cause, such as gastro-intestinal bleeding.

  • if your cat develops the antibody reaction, you will probably have to use blood transfusions to control the anaemia instead. At the present time I know of no other treatment, except possibly switching to Aranesp if you are currently using another ESA.

  • if your cat, as is most likely, does not develop the antibody reaction, s/he will have no problems with anaemia and all its attendant side effects in the future.

Ultimately it is your decision whether to use an ESA. There have been trials into feline alternatives (see below) but, according to the researchers involved, none of these studies is expected to result in the commercial availability of alternative treatments in the foreseeable future. 

 

If you do decide to use an ESA, Aranesp (darbepoetin alfa) is probably the best choice, and is what I would try to use if I needed to use one for my cat.

 


Using Aranesp in Cats Who Have Developed the Antibody Reaction to Epogen, Procrit or Eprex


 

It is not recommended to use any form of ESA in a patient who has reacted to another form (in other words, if you have developed the antibody reaction to Epogen, it is not advisable to use Aranesp instead). Since there are some differences between Epogen and Aranesp, some US vet schools have tried to maintain cats who have developed the antibody reaction to Epogen or Eprex by using blood transfusions for several (6-8) weeks, and then starting them on Aranesp, in the hope that the cats will not also develop an antibody reaction to Aranesp. Apparently there is anecdotal evidence that this approach worked for one cat but it did not work for any others. Sometimes prednisone, a corticosteroid, is used in the interim period before starting treatment with Aranesp.

 

One person whose cat may have developed the antibody reaction to Epogen (this person's vet had recommended a stop/start approach, which is not advisable because it may increase the risk of the antibody reaction) tried to switch to Aranesp. He found that using Aranesp alone or Aranesp and prednisone did not help his cat, but using it in conjunction with both prednisone and chlorambucil (Leukeran), an immunosuppressive drug commonly used in the treatment of cancer, did help for a while. This regimen was based on the successful treatment plan for a woman who also developed the antibody reaction. However, Leukeran can itself cause anaemia.

 

Pure red cell aplasia secondary to epoetin alfa responding to darbepoetin alfa in a patient on peritoneal dialysis (2004) Asari A R Gokal R Journal of the American Society of Nephrology 15 pp2202-7 reports on the case of a human patient who developed the antibody reaction to Epogen who was successfully switched to Aranesp.

Successful reintroduction of a different erythropoiesis stimulating agent after pure red blood cell aplasia: relapse after successful therapy with prednisone (2005) Andrade J, Taylor PA, Love JM, Levin A Nephrology Dialysis Transplantation 20 pp2548-51 discusses the case of a woman who developed the antibody reaction and who was helped by prednisone.

Erythropoietin, cure or nightmare (2004) Chan SK, Chan CK, Chow CC is a Presentation to the Hong Kong Society of Nephrology Interhospital Meeting about a woman who developed the antibody reaction and who was helped by prednisone and chlorambucil.

Mar Vista Vet has some information about chlorambucil (Leukeran).

 


Feline Erythropoietin (rfEpo)


 

Feline Erythropoietin (rfEpo)


Feline erythropoietin is not commercially available currently, but was developed in small quantities for use in two feline trials, one in 2010 at Colorado State University and one in 2002 at Cornell.

 

CSU Feline Erythropoietin Trial (2010)


The sponsor of this study at the Veterinary Teaching Hospital at Colorado State University engineered a new feline erythropoietin (rfEpo). In 2010 this was administered to 18 healthy cats at varying doses and on average, raised the red blood cell count 25% or more with no side-effects and the effect lasted more than one month.

 

Cornell Feline Erythropoietin Trial (2002)


A new synthetic form of feline erythropoietin was developed at Cornell University in the USA, and a one year trial for CKD cats was completed there in November 2002.

 

Expression, bioactivity and clinical assessment of recombinant feline erythropoietin (2004) Randolph JF, Scarlett JM, Stokol T, Saunders KM and McLeod JN American Journal of Veterinary Research 65(10) pp 1311-1450 explains the outcome of the study. Unfortunately, whilst the rfEpo was effective at curing anaemia in the study cats, even in those cats who had previously had an antibody reaction to human erythropoietin, 26% of the cats receiving feline erythropoietin (and who had never used human erythropoietin) developed an antibody reaction to the feline erythropoietin.

 

Feline Erythropoietin Gene Studies


 

2011 University of California at Davis


The Winn Feline Foundation reports on a 2011 grant to the University of California at Davis College of Veterinary Medicine to create a feline erythropoietin gene, with a view to using this later in clinical trials.

 

Lentiviral gene therapy strategy for the in vitro production of feline erythropoietin (2012)  Vapniarsky N, Lame M, McDonnel S & Murphy B PLoS One 7(9) e45099 discusses the outcome of the research. 

 

2000 Ohio State University


A 2000 study at Ohio State University College of Veterinary Medicine investigated the development of a feline erythropoietin gene. The gene that makes feline erythropoietin was implanted into the leg or back muscle by an intramuscular injection similar to a vaccination. Tests conducted on healthy cats showed that this increased PCV levels over a seven week period following the injection.  

 

Results were mixed with some cats responding extremely well and others less well, but overall the trials were encouraging. Once the gene is implanted, the cat should produce erythropoietin on its own, and in the trials responsive cats had been doing so for up to one year. Further trials may be conducted in due course.

 

Transfer of the feline erythropoietin gene to cats using a recombinant adeno-associated virus vector (2000) Beall CJ, Phipps AJ, Mathes LE, Stromberg P, Johnson PR Gene Therapy 7 (6) pp 534-539 describes the beginning of the trial.

Back to Page Index

This page last updated: 07 October 2013

 

Links on this page last checked: 18 August 2012

   

*****

 

TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

 

I have tried very hard to ensure that the information provided in this website is accurate, but I am NOT a vet, just an ordinary person who has lived through CKD with three cats. This website is for educational purposes only, and is not intended to be used to diagnose or treat any cat. Before trying any of the treatments described herein, you MUST consult a qualified veterinarian and obtain professional advice on the correct regimen for your cat and his or her particular requirements; and you should only use any treatments described here with the full knowledge and approval of your vet. No responsibility can be accepted.

 

If your cat appears to be in pain or distress, do not waste time on the internet, contact your vet immediately.

 

*****

Copyright © Tanya's Feline CKD Website 2000-2012. All rights reserved.

 

This site was created using Microsoft software, and therefore it is best viewed in Internet Explorer. I know it doesn't always display too well in other browsers, but I'm not an IT expert so I'm afraid I don't know how to change that. I would love it to display perfectly everywhere, but my focus is on making the information available. When I get time, I'll try to improve how it displays in other browsers.

 

You may print out one copy of each section of this site for your own information and/or one copy to give to your vet, but this site may not otherwise be reproduced or reprinted, on the internet or elsewhere, without the permission of the site owner, who can be contacted via the Contact Me page.

 

This site is a labour of love, from which I do not make a penny. Please do not steal from me by taking credit for my work.

If you wish to link to this site, please feel free to do so. Please make it clear that this is a link and not your own work. I would appreciate being informed of your link.

 

The group is hosted on yahoo!groups, part of yahoo. It has its own address separate from Tanya's website. You can either click here or copy and paste this link into your browser:

 

http://pets.groups.yahoo.com/group/tanyas-ckd-support/

 

If you are already familiar with yahoo!groups, just click on the link and apply to join (and don't forget to complete the short questionnaire you'll be sent), but if you'd like to know more about how the group works, read on.

 

I own and run the group, but I am ably assisted by two moderators, Anne V and Anne A. They help with membership queries, approve messages, and do lots of boring admin stuff behind the scenes to help the group run smoothly for the members.

 

The group has various sections, including a photos section and a realtime chat function but for most people the most important part of the group is its message section. Basically, a member who wants support, vet recommendations, or to hear how others are coping with a particular problem, sends a message to the rest of the group. Other members then respond if they can. All messages sent to the group are stored in a message archive which members can search if they wish.

 

The group is private, i.e. messages sent to it are only visible to members, so people are not posting to the internet at large. The names of group members are also private, so nobody will know you are a member unless you choose to send messages to the group.

 


Joining the Group                                                                                                                        Back to Page Index


 

There are two ways to join the group, via the group's website or via e-mail:

 

How to Join the Group via E-mail


Just send an e-mail to

tanyas-ckd-support-subscribe@yahoogroups.com

You should then receive an e-mail in response asking you to confirm that you definitely want to join the group. Just click Reply and send.

 

If you join the group via e-mail, you will be able to send and receive e-mails to the group, but you will not be able to access the group website and read the message archives or look at the photos. If you wish to do that, you will need to set up a yahoo! ID by visiting the group website.

 

How to Join the Group via the Web


You can visit the group's homepage and follow the instructions. If you do this, yahoo!groups will help you set up your yahoo! ID, which gives you access to the group message archive etc. A yahoo! ID is not the same thing as an e-mail address.

 

Here are the steps to follow. Don't worry, this all sounds far worse than it is! You should find that in practice it all works more smoothly than it sounds when you're trying to explain it in writing:

 

Existing yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Sign in and link Tanya's Support Group to your existing account.

  4. Choose the e-mail address you wish to use for the group (see below).

  5. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  6. Choose your message delivery options (see below).

  7. Scroll down and click on the blue Join button at the bottom right of the page.

New yahoo! ID

  1. Go to the group website: http://pets.groups.yahoo.com/group/tanyas-ckd-support/

  2. Click on the Join this Group button and you'll be taken to a Sign In to Yahoo! page.

  3. Scroll down a little and click on the Create New Account button.

  4. On the next page you can create your new account. Some people are somewhat inventive in their responses, but in such cases it is important to remember what responses have been given in case the information is needed later to access the account. I can't see any of this stuff, it's entirely private between you and yahoo!groups, so I cannot help in case of later queries. 

  5. Once the account is successfully set up, you'll be taken to a Congratulations! page.

  6. Before you click on the Continue button on the Congratulations! page, untick the box that makes yahoo! your homepage (unless that is what you want).

  7. Also click on the Edit Marketing Preferences link below the Continue button. This takes you to another page where they helpfully opt you in to everything, so go through and set it as you wish.

  8. Then on the same separate page click on Account Info at the top of the page. You will be asked for your password again and taken to the Account Info page. Click on Profile and opt out of the various choices as you wish. The key thing is, you do have choices here, you can make things as public or private as you wish.

  9. Now click on the Continue button on the original page. You will be taken back to the group page to choose your membership settings.

  10. Choose the e-mail address you wish to use for the group (see below).

  11. There is a little box for you to tell me why you would like to join the group. You don't need to be inventive or fancy, it's not a competition, it's just an extra check by yahoo!groups to keep spammers out.

  12. Choose your message delivery options (see below).

  13. Scroll down and click on the blue Join button at the bottom right of the page.


Membership Settings                                                                                          Back to Page Index


 

There are various choices you need to make regarding your membership of the group. The most important are which e-mail address to use, and which way you read messages sent to the group by group members.

 

Membership Settings: Your E-mail Address


You need to decide which e-mail address you wish to use for the group. If you have created a yahoo! ID, yahoo!groups will normally have also set up a free yahoo! e-mail account for you based on your new yahoo ID. You can use this e-mail address to access the group if you wish, but it's not essential, you can use any e-mail address you wish. Since yahoo! is now scanning messages for advertising purposes (similar to gmail), I would recommend not using yahoo! e-mail if possible (though it would probably be better than using your work address for private stuff).

 

If you do not want to use your free yahoo! e-mail address, click on Add e-mail address to add a different one. Be aware, if you don't add a new address here, yahoo! will use the yahoo! e-mail address as a default address. So if you don't receive the membership questionnaire, it may well be because it's gone to your new yahoo! e-mail address.

 

If you ever wish to change the e-mail address you are using for the group, you can do that here:

http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

 

Membership Settings: Message Delivery


This sets up how you will access messages that are sent to the group.

 

This is a pretty active group. If you're looking after your CKD cat, you want support but you probably don't want a full inbox all the time. To help you manage this issue, you have three options for messages, and you can switch between them all as you wish:

  1. Individual E-mails

  2. Daily Digest

  3. Web Only (No e-mail)

Individual E-mails


This is the default setting. If you apply to join the group via e-mail, you will end up with this setting. If you apply to join the group via the group's webpage, if you don't choose one of the other settings, this is the one you will end up with.

 

This setting means that as soon as somebody sends a message to the group, it is sent directly to your inbox. It's a good choice if you might want to know immediately if somebody has responded to you, or if you would like to store some of the group messages for your reference. It's also good for being able to quickly delete messages which don't interest you.

 

The downside is that this is a busy group, averaging 50-100 group messages each day, so your inbox can quickly get full. One solution is to create a folder to use for group messages. All messages sent to the group have a tag in the subject line [tanya-crf] so you can filter all messages from the group to a new folder using this tag if you wish.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Message Digest


This means that you receive e-mails from the group, but yahoo!groups waits until there are about 25 messages available and sends them to you all in one go. With this option, you would therefore only receive 2-4 e-mails a day from the group, but it means you have to wait for responses (though you can still check on the group website for messages) and it can be more difficult to find what you are looking for within each digest.

 

With both individual e-mail and message digest options, you can also choose the format of messages sent to you (Display Format), either Fully Featured (html, pretty colours etc.) or Traditional (plain text).

 

Web Only (No Mail)


This means that you receive no messages at all from the group. This is a wise choice if you are using a work e-mail address, or if you cannot cope with the group's message volume. With this system you simply go to the group's website and read the messages that interest you there. Even if this is not your usual choice, it can be helpful to use this option if you are going on holiday.

 

So make your choices, then click the Join button at the bottom right of the page.

 


Important: Membership Questionnaire                                                           Back to Page Index


OK, so you've successfully applied to join the group. However, there is one more thing you need to do in order to join. I want to protect the group members from spammers, so whichever way you apply to join the group, you will receive a short questionnaire asking:

  1. Your first name

  2. The country where you live

  3. Your CKD cat's name and age

You need to respond to this before your membership will be approved.

 

Please don't worry about saying "the right thing." This is not a test to see if you are "good enough" for the group, everybody is welcome here, whoever they are or wherever they come from, as long as they want to help their cat. This questionnaire is basically just to reassure us that you are a real person applying to join rather than somebody trying to sell stuff and spam the group, but it also enables us to tailor our responses to your group messages e.g. if we moderators know where you live, we will not suggest treatments not available there.

 

Please note, only the two Annes and I can see your responses to these questions. The group will not know anything about you unless you choose to introduce yourself.

 

Once you respond to the questionnaire, your membership application should be approved very quickly (most people are approved within two hours or less).

 

Occasionally the questionnaire goes missing. You think we haven't sent it, and we think you haven't responded! If we haven't heard from you five days after you apply to join, we will send you a reminder. Unfortunately, we can only use the address you've used to sign up for the group, so if you've accidentally used your new yahoo e-mail address without realising it (see above), you won't see either the questionnaire or our reminder. If you don't hear from us, please simply write to us at tanyas-ckd-support-owner@yahoogroups.com and let us know. Please respond to the three questions in your response and we will either approve you (if your membership is pending) or send you a personal invitation to join the group (if your membership application has disappeared into a black hole).

 


Messages                                                                                                                                          Back to Page Index


 

Message Options: Sending Messages


You don't have to post, you can just lurk if you prefer.

 

If you wish to change the name that appears on messages you send to the group, Yahoo! explains how you can do that.

 

Starting a Thread


  1. You can simply send an e-mail to ask your question by sending it to tanyas-ckd-support@yahoogroups.com.

  2. You can go to the group website, click on Post Message in the sidebar on the left, and then write your message there.

Replying to an Existing Message


Messages sent in response to another message on the group also go directly to the group, not to the individual to whom you are replying. Therefore if you wish to respond to a message somebody else has sent, you can simply click reply on your e-mail programme. If you reply via the group website, you can click on the message in the group archives, then click reply which is top left above the message.

 

If you're changing the subject, or replying to a Digest (which have the subject line of Digest No. xxx), please change the subject line appropriately to something more meaningful. And please remove everything except that to which you are replying.

 

If you wish to reply privately to somebody, you will need to press reply, then delete the group e-mail address and paste their personal e-mail address into the To: line if you are using e-mail. If you are replying via the group website, you will see a little envelope over on the right under the person's name. If you click on that, your message will go to that person.

 

Message Content


You are welcome to discuss anything relating to care of your CKD cat. We do have a few guidelines we ask people to follow though:

  1. Please do not refer to vets or vet clinics by name for legal reasons. Just say "my vet" or "Dr J".

  2. Please do not ask for money or other donations.

  3. Since this is a very busy group, we ask that condolences are sent privately to the bereaved group member. Certain other messages should also be sent privately e.g. short "me too" messages, off topic posts etc.

  4. Please trim your posts.

Moderation of Messages


When you first join the group, your messages will be moderated for a short while. This means that they will not reach the group immediately, but will first be read and approved by one of the moderators. We do this to ensure that:

  1. you are not a spammer;

  2. you are keeping to other group guidelines (e.g. not naming your vet publicly);

  3. you are trimming your messages appropriately.

If you comply with the group guidelines sent to you when you join the group, you will be taken off moderation quickly. The main reason people stay on moderation is because they do not trim their posts. So please read up on this in the group guidelines. If you get stuck, just ask for help.

 


Leaving the Group                                                                                                Back to Page Index


 

Some people decide to leave the group. Their cat may have died, or they may find the message volume is too much, or they simply decide it's not the place for them. Leaving is fine, but if you're thinking of leaving simply because you cannot cope with message volume, please consider changing your message options first, such as by going no mail. This means your inbox will not be full, but you can still reach out for support quickly when you need it.

 

If you are leaving because your cat has died, please consider joining our sister group, Tanya's Feline Loss Support:

http://pets.groups.yahoo.com/group/tanyas-feline-loss/

 


Conclusion                                                                                                            Back to Page Index


I do hope you've decided to join Tanya's CKD Support Group! It can give you support, it can give you hope. It can make you smile too - where else would people share your thrill at hearing that your constipated cat has pooped? (Believe me, when you've been dealing with CKD for a while, things like this are real triumphs which can absolutely make your day).

 

I personally read every message sent to the group. I don't respond to every post (my priority is running this website) but I do keep an eye on things and post occasionally if I can add to what has already been said.

 


Group Quick Links                                                                                               Back to Page Index


Some of these only work if you are already a member of the group.

 

Weblinks


Group homepage:                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/

Managing your membership options:                  http://pets.groups.yahoo.com/group/tanyas-ckd-support/join

Messages archive                                                 http://pets.groups.yahoo.com/group/tanyas-ckd-support/messages

 

E-mail Addresses


Sending a message to the group via e-mail:        tanyas-ckd-support@yahoogroups.com

Group owner e-mail address:                                 tanyas-ckd-support-owner@yahoogroups.com

Joining the group via e-mail:                                   tanyas-ckd-support-subscribe@yahoogroups.com

Leaving the group via e-mail:                                  tanyas-ckd-support-unsubscribe@yahoogroups.com