Nausea, vomiting and loss of appetite are some of the most common problems
in CKD cats.
There are a variety of possible causes, and there may be more than one
reason for a cat to be showing these symptoms.
Fortunately, in most cases there are treatments which can help make the
cat feel much more comfortable, but in order to know which treatment would
work best, you need to know the most likely cause in your cat's case.
Toxins caused by the kidney disease are one of the most likely culprits in
cats with creatinine over 3 mg/dl (USA) or 265 µmol/L (international),
though they may also be a problem in cats with lower creatinine levels.
There are a number of treatments that can help.
Causes of
Loss of Appetite, Nausea and Vomiting
Common Causes
Unfortunately, there are a large number of possible causes of nausea,
vomiting and loss of appetite in CKD cats. It can therefore be confusing
trying to decide what might be the cause in your cat's case. To help you
narrow it down, I would scan through the list of symptoms on the
Index
of Symptoms and Treatments page to see if any of them look familiar.
Alternatively, the list below outlines some of the possible causes of nausea,
vomiting and loss of appetite. If you already know that your cat has a
particular problem, say, high phosphorus levels, you can click on the
appropriate link where you will find more information on other symptoms
associated with that condition, which may help you narrow down the cause:
Ask your vet to rule out any of these causes or to treat them if they are
present. Treating any that are present should help stop the vomiting
and appetite loss and make your cat feel more comfortable. In some
cases (e.g. controlling high phosphorus levels), it may also help slow the
progression of the CKD.
Uraemic Toxins
Even if you rule out or treat the above causes, your cat may still
continue to have problems with vomiting, nausea and appetite loss,
so the chances are you need to read this page even if your cat has some of
the above problems too. Take a look at the list of symptoms
below and see
if they sound familiar - most people find they do.
In such
cases, the problem may be caused by toxins.
As the kidneys gradually lose their ability to regulate
and remove waste products effectively, these waste products build up in
the blood. This is called
uraemia and can make a cat feel very unwell,
because it can affect an area in the brain but outside the blood-brain
barrier called the
central chemoreceptor trigger zone.
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease (2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine &
Surgery18 pp219-239 mentions this.
Although
BUN
is not itself a toxin, there is a correlation between it and other toxins
which are less easy to measure. Therefore, the higher your cat's BUN or
urea level, the higher the overall toxin load will be, and the more likely it is that s/he
will feel sick and vomit.
Feline CKD: Current therapies - what is achievable?
(2013) Korman R & White J Journal of Feline Medicine and Surgery
15(S1) pp29–44 says
"Cats in CKD stages 3-4 often demonstrate gastrointestinal signs of uraemia
(eg, inappetance, nausea, vomiting, stomatitis, gastrointestinal
ulceration, diarrhoea, colitis) and addressing these may improve quality
of life."
Gastric
Hyperacidity (Excess
Stomach Acid)
Gastrin is a gastrointestinal hormone which
stimulates the secretion of gastric acid, which helps the stomach digest
food.
The kidneys are responsible for the excretion of gastrin, but in CKD
this function may not work so well, resulting in the gastrin remaining in
the stomach and potentially stimulating the production of too much gastric
acid.
Feline CKD: Current therapies - what is achievable?
(2013) Korman R & White J Journal of Feline Medicine and Surgery
15(S1) pp29–44 says
"Gastrin is excreted by the kidneys and the concentration increases with
CKD progression, increasing gastric acidity and the risk of ulceration."
Gastric hyperacidity (excess stomach acid)
can make you feel very unwell. In severe cases stomach ulcers may develop,
which may cause
gastrointestinal bleeding.
It has been widely accepted for many years
that excess stomach acid is a concern for CKD cats, but there is currently some debate as to how big
a role it plays in the symptoms commonly seen in CKD
cats.
Chronic use of maropitant for the management of
vomiting and inappetance in cats with chronic kidney disease: a blinded
placebo-controlled clinical trial (2014) Quimby JM, Brock WT,
Moses K, Bolotin D, Patricelli K Journal of Feline Medicine &
Surgery17(8) pp692-697says "Interestingly, the exact mechanism of why CKD cats
suffer from decreased appetite and vomiting is not currently known. Gastrin hormone that is responsible for stomach acid production is
elevated in CKD cats; however, increased stomach acidity and stomach
ulceration have not been document [sic] in humans or cats with CKD. It is
suspected that CKD cats have an increase in toxins referred to as uremic
toxins that trigger the vomiting center (chemoreceptor trigger zone of the
area postrema) in their brains."
Relationship among serum creatinine, serum gastrin,
calcium-phosphorus product, and uremic gastropathy in cats with chronic
kidney disease (2014) McLeland SM,
Lunn KF, Duncan CG, Refsal KR & Quimby JM Journal of Veterinary Internal
Medicine28(3) pp827-37 compared CKD cats with healthy cats.
They found that 84% of the CKD cats exhibited loss of appetite and 45%
exhibited vomiting, but although the CKD cats did have higher levels of
gastrin compared to the healthy cats, there did not appear to be any
correlation with the severity of the CKD. The study states
"Gastrointestinal signs in these animals may not necessarily be the result
of gastric lesions such as gastric ulceration and inflammation, but
perhaps the consequence of circulating uremic toxins interacting with the
chemoreceptor trigger zone in the brain."
Evaluation of gastric pH and serum gastrin
concentrations in cats with chronic kidney disease
(2017) Tolbert MK, Olin S, MacLane S,
Gould E, Steiner JM, Vaden S & Price J Journal of Veterinary Internal
Medicine 31(5) pp1414–1419 measured gastric pH in healthy cats
and CKD cats over a maximum period of twelve hours, hypothesising that
cats with excess stomach acid would have lower gastric pH. The study found
that this was not the case and concludes "These findings suggest that cats with CKD may not have gastric
hyperacidity compared to healthy cats and, therefore, may not
need acid suppression. Thus, further studies to determine if
there is a benefit to acid suppression in cats with CKD are
warranted."
Whatever the cause, a CKD cat who exhibits the symptoms listed below needs
help. Generally speaking,
these will be cats with
creatinine
over 3 mg/dl (US) or 265 µmol/L (international) (IRIS stages 3 or 4).
If your cat has relatively low kidney
bloodwork values (creatinine of 2.5-3 mg/dl US, 200-300 µmol/L international)
but nevertheless seems to vomit a lot, it might possibly be because of
CKD-related toxins, but I would also ask your vet to rule out
pancreatitis.
Symptoms
There is no
test as such for toxins, but these are
some of the symptoms you might see (though some of these may also be due
to other causes, as mentioned under each category):
Loss of
appetite is very common in CKD cats and may well be caused by toxins. Human
CKD patients have reported that
their sense of smell and sometimes taste are impaired; this is thought to
be caused by uraemic toxins, and probably occurs in cats too.
Cats who do
not eat are at risk of developing a potentially life-threatening condition
known as hepatic lipidosis;
Mar Vista Vet
has more information about this. Therefore, it is important to try to find the cause of the inappetance and
treat it as quickly as possible.
Nausea
Nausea can
be hard to detect, though it is often manifested in a lack of appetite. The
cat may also lie scrunched up, looking uncomfortable.You may hear the
stomach gurgling. It is perfectly
possible for a cat to have nausea but not to vomit.
Many CKD cats
vomit regularly without treatment.
Dr D Polzin states in
Chronic kidney disease (2007)
Delaware Valley Academy of Veterinary Medicine "vomiting
is reportedly found in one quarter to one third of cats with clinical
signs of uremia."
Vomiting may be seen alone or in conjunction with the other symptoms in
this section.
Sometimes
there may be blood in the vomit - bright red blood is fresh blood, whilst
older blood looks like ground coffee grains. This may be a sign of
mouth ulcers
or of
gastrointestinal bleeding,
but you should contact your vet immediately if you see this symptom - our
George, a non-CKD cat, vomited old blood as the first symptom of severe
liver disease.
Cats who
vomit a lot are more likely to become
dehydrated.
There is a
difference between vomiting and regurgitation. Vomiting is usually
accompanied by a lot of abdominal movement, whereas regurgitation happens
suddenly and with less warning. Vomiting means the cat is emptying the
stomach, whereas regurgitation is where food has not yet reached the
stomach but is being ejected from the oesophagus more or less intact,
often because of eating too fast or hairballs. Regurgitation is often
sausage-shaped.
Veterinary Partner
explains the difference and
has videos showing vomiting versus regurgitation.
Cats who
vomit immediately after eating may have a gastric motility problem -
ranitidine may help with
this.
Occasionally vomiting is caused by
constipation,
particularly if your cat vomits before, during or immediately after using the litter tray.
If you are giving your cat sub-Q fluids and s/he regularly vomits after
fluids, this may because of the
type of fluid
used.
Why so many vomiting cats? Getting the diagnosis
(2011) Little S Presentation to the 36th World Small Animal
Veterinary Association World Congress has a flow chart for
narrowing down the cause of the vomiting.
Vomiting does not just include food -
the classic symptom in CKD cats is to vomit clear or white foam.
This is often one of the first signs that people notice when their cat is
developing CKD.
Vomiting Water
Sometimes
CKD cats drink a lot on water in one go, then vomit all or most of it up
shortly afterwards. This may be a sign of excess stomach acid. It is possible
that the cat has an urge to drink before vomiting so as to dilute the
stomach acid.
Vomiting in the Morning
CKD cats
often vomit in the morning.
This tends to happen because if a cat goes a long time
without eating (such as overnight), excess stomach acid has more time to
attack the stomach lining and cause vomiting.
Lip Licking
This can be
a sign of nausea and uraemia. It may also be a sign of
dehydration
or possibly pain. Less commonly, it can be a sign of
anaemia. In rare cases it may be caused
by longer term (over three months) use of
Cats
commonly eat grass in order to help themselves vomit,
particularly if they want to bring up a hair ball. CKD cats may also eat
grass for this reason, though they may do it because they feel nauseous
generally, and sometimes you feel a little better if you can actually
vomit. It is normally fine to allow your CKD cat to eat grass, as long as
it has not been treated with pesticides.
This can be
a sign of nausea and uraemia. Occasionally it is a sign of
dehydration.
Playing with Water
Some cats
like to play with their water bowls from an early age, but some CKD cats
develop a bit of an obsession with water, and may play with their water
bowl or paw at the water. You may see other new behaviours, such as
drinking from showers or gutters, or hanging around sinks and begging for
fresh running water from the tap. All these types of behaviour may
indicate uraemia. Other possible causes include
dehydration or
diabetes.
Sniffing or Licking or Looking at Food, then
Walking Away
The cat may
approach the food bowl and sniff or lick the food, then walk away. This is a
pretty classic sign of uraemia in a CKD cat, but it may also indicate
mouth ulcers.
Pawing at the Mouth
The most
common reason for this is
dental problems,
but occasionally it is a sign of uraemia.
Increased
Drinking (Polydipsia)
Increased
drinking is common in CKD cats because they usually have problems
maintaining hydration. However, it can also be a symptom of uraemia.
The cat may drink more because, according to
A glass of water immediately increases gastric pH in
healthy subjects (2008) Karamanolis G, Theofanidou
I, Yiasemidou M, Giannoulis E, TriantafyllouK & Ladas SD Digestive
Diseases and Sciences 53(12) pp3128-3132, drinking water may
briefly (only for a few minutes) reduce levels of stomach acid.
In some
cases increased drinking may indicate diabetes.
Licking Gravy Only
The cat may
lick the gravy only and leave any solid food behind. However, this may not
indicate uraemia in all cats, only if it is a new behaviour - my cats
do this all the time and they are healthy, they just prefer pâté-type
foods. Another possible cause is
dental problems.
Sitting Hunched Up
Since cats
with uraemia have sore tummies, they may sit in a hunched up,
uncomfortable position ("meatloafing"). In the worst case, this may indicate
crashing, but only
if you also see the symptoms described there.
Although it is not possible to test for toxins,
if your cat is showing any of the
symptoms described
above
(e.g. vomiting white foam),
it is usually worth trying treatments and seeing if your
cat feels better. Many people find simply using the appropriate treatments
on this page (with their vet's approval, of course) helps their cats to
feel noticeably better.
Feline CKD: Current therapies - what is achievable?
(2013) Korman R & White J Journal of Feline Medicine and Surgery
15(S1) pp29–44 says
"Cats in CKD stages 3–4 often
demonstrate gastrointestinal signs of uraemia (eg, inappetance, nausea,
vomiting, stomatitis, gastrointestinal ulceration, diarrhoea, colitis) and
addressing these may improve quality of life."
Although many CKD cats benefit from the treatments described below, the
best treatment depends upon the cause of the problem. For example, many
cats with anaemia lose
their appetites, and the treatments on this page will not help with that,
you need to treat the anaemia. You can check the
It used to be the case that people in the USA were routinely offered
treatments for reduced appetite, vomiting or nausea and
people in Europe rarely were. Although things are slowly improving, it is
still quite possible that if you are in the UK in particular, you will be
offered nothing. In this case, the links immediately below from UK-based
experts may help you persuade your vet to let you treat for these
problems.
IRIS treatmentrecommendations for CKD
(2015) International Renal Interest Society
state "Vomiting should be actively managed in cats with CKD and
nausea should always be considered as a potential contributory cause in
cats with inappetence." It recommends treating reduced appetite, vomiting
or nausea "with
a proton pump inhibitor (e.g., omeprazole) and an antiemetic (e.g., maropitant
or ondansetron). However, further investigations are needed on the use of
these drugs to determine whether they are useful for managing gastrointestinal
disturbances in cats with CKD and uraemia."
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease (2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine &
Surgery18 pp219-239 are more forthright, stating "Centrally
acting antiemetics such as maropitant, mirtazapine, ondansetron and
dolasetron should be considered for management."
All the treatments mentioned by IRIS and ISFM are discussed
below.
I recommend a staged approach. as does
11 guidelines for conservatively treating chronic
kidney disease (2007) Polzin D,
Veterinary MedicineDecember 2007, which
says "H2 blockers are most commonly used, and few adverse effects have
been attributed to their use. Antiemetics are typically added when
anorexia, nausea, or vomiting persist despite the use of an H2 blocker."
Feline CKD: Current therapies - what is achievable?
(2013) Korman R & White J Journal of Feline Medicine and
Surgery
15(S1) pp29–44 says
"Antiemetic agents are typically added in a stepwise (i.e., one
at a time) progression dependent on patient response. The
authors typically use omeprazole with maropitant or ondansetron
if inappetance or nausea persist….and ranitidine is used in cats
that demonstrating signs of ileus (e.g., identified on
ultrasound)."
(2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd
K Pfizer Roundtable Discussion has some information on how to
treat vomiting in cats.
Here is a possible staged treatment plan for you to
discuss with your vet:
The simple natural treatments come first, because they are simple,
effective, inexpensive, and can be done immediately and without a vet
visit (though please inform your vet if you wish to try slippery elm
bark).
For some cats,
especially those in early stage CKD, these are the only treatments they
need:
If the treatments in Step 1 don't seem to be helping after a couple of days, move onto the
acid blockers, which are a group of
medications commonly used to control excess stomach acid. You can use these in conjunction with the natural
treatments.
There is some debate at present as to whether CKD cats actually suffer
from excess stomach acid, see
above, but these medications do seem to help many CKD cats and are
cheap and widely available, so I would discuss their use with your vet.
These
medications are usually very effective for nausea and vomiting. They can
help cats who do not respond fully to the treatments in Steps 1 and 2, or
whose CKD is more advanced. They may also be useful to help cats with additional issues, such as gastric mobility
problems, or cats
with concurrent pancreatitis or IBD. They can usually be used in
conjunction with the medications outlined above:
It is usually safe to use more than one of these treatments at the same time, e.g.
slippery elm bark and famotidine, but check with your vet first. Don't use
Pepto-Bismol
or
antacids such as Tums or Mylanta.
Natural Treatments
The beauty of these treatments is that they need little effort, are not
particularly invasive and require very little outlay, yet for some cats they are
extremely effective. I therefore recommend trying them to see if they
help. If they are going to help, you would normally see a difference (e.g.
reduced vomiting) within a couple of days.
Normally a cat
eats with the mouth lower than the stomach, but in CKD cats this can cause
stomach acid to enter the oesophagus and trigger acid reflux. Keeping the
cat's food and water bowls higher than the stomach can help minimise this
problem and may encourage your cat to eat and drink more.
Standing bowls on an upside-down flower pot can often create the correct
height for your cat and provide a sturdy base: choose a flower pot of the
appropriate height for your cat. Some pet stores also sell food dishes on
legs, which are approximately 6 inches (15cm) high.
Classy
Cat Dishes sell raised
stoneware bowls for about US$40. You can also find them on
Amazon. Contrary to what the first Amazon
review says, I have absolutely nothing to do with Classy Cat Dishes, and
definitely do not benefit financially from their sale. I am simply a
satisfied customer of many years standing. The bowls I purchased in 2008 are still in great shape, and my cats love them
(in fact, they refuse to eat from anything else). My
cats do not have CKD, but I have noticed they eat more if I feed them from
these bowls. To the left you can see my silly kitten using his Classy Cat dish
in his own inimitable way - he did finally get the hang of it!
Necoichi
raised bowls are also available from Amazon USA. These are much cheaper
and have good reviews too, though some people think they are too small and/or
too low.
sells some raised bowls which at least one member of my
support group has used, though I think these would be too deep for some
cats, especially Persians.
The Art of Doing Stuff has ideas on
making your own raised bowls, though I think the ones she uses are too
deep for cats.
Feeding Before Bedtime
You may find that your cat has more stomach upsets at night
which cause vomiting during the night or first thing in the morning. This
happens because if a cat goes a long time without eating, excess
stomach acid has more time to attack the stomach lining.
Try to
ensure that your cat eats before bedtime in order to prevent this -
keeping food constantly in the stomach means the acids are more likely to
attack the food rather than the stomach lining. It may also be worth
setting up an automated feeder on a timer with food in it to keep your cat supplied with food
throughout the night. There are links to such feeders
here.
Slippery Elm Bark
If you wish to pursue natural methods of controlling excess stomach acid and the
accompanying vomiting, nausea and loss of appetite, a herbal remedy
called slippery elm
bark (SEB) is often very effective. It soothes the digestive tract, so it can also help with
both constipation
and
diarrhoea.
The
Holistic Treatments page has more detailed information on SEB.
Please inform your vet if you wish to use slippery elm bark.
Acid Blockers
These medications can be very effective for controlling excess stomach
acid, which in turn may greatly reduce vomiting and nausea and increase appetite.
There are two main classes of acid blocker,
histamine H2 antagonists, such as famotidine and ranitidine, and
proton pump inhibitors (PPIs), such as omeprazole. Historically
people would use famotidine or ranitidine for their CKD cats,
but omeprazole is becoming more popular and seems to be very
effective.
Recently there has been a lot of debate in scientific circles as
to how effective the histamine H2 antagonists are in CKD cats.
This is largely because of a study,
Evaluation of gastric pH and serum gastrin
concentrations in cats with chronic kidney disease
(2017) Tolbert MK, Olin S, MacLane S,
Gould E, Steiner JM, Vaden S & Price J Journal of Veterinary Internal
Medicine 31(5) pp1414–1419, which measured gastric pH in healthy cats
and CKD cats over a maximum period of twelve hours, hypothesising that
cats with excess stomach acid would have lower gastric pH. The study found
that this was not the case and concludes "These findings suggest that cats with CKD may not have gastric
hyperacidity compared to healthy cats and, therefore, may not
need acid suppression. Thus, further studies to determine if
there is a benefit to acid suppression in cats with CKD are
warranted."
Because of this study, I am hearing from people whose vets are
now reluctant to prescribe histamine H2 antagonists in
particular, even if
they have used them before. I think this response is premature,
and may be caused by some statements made in the study, e.g. it
states "Chronic administration of acid suppressants has been
associated with calcium and PTH derangements, osteoporosis, and
pathologic fractures in at risk human populations."
That statement refers to humans, not to cats. In addition, this
study looked at only ten CKD cats, 50% of whom were in IRIS
Stage 2, so below the level where these medications
are normally used. Even the study itself does not advise
against giving them, saying "additional
studies are warranted both to evaluate gastric pH in cats with
later stages of CKD as well as to determine if there is an
actual benefit of acid suppression in cats with CKD."
Although there is little evidence that acid blockers work for CKD cats (see
above for more on this), in practice they do seem to help
many cats, and many people still use them, not least because they are cheap and easily
available over the counter in most countries (though please do
not use any of these treatments without your vet's permission).
It must also be borne in mind that some CKD cats also
have pancreatitis, and such cats do benefit from the use of acid blockers.
Although these medications can be purchased
over the counter, please do NOT give them without first discussing them
with your vet, particularly if your cat has advanced CKD, because they are
excreted by the kidneys so may not be appropriate.
Drug dose adjustments for disease
(2010) Trepanier LA CVC in Washington Proceedings discusses
the need to adjust dosing levels for some medications when diseases
including CKD are present.
Once you start giving these medications, it is usually better to
continue giving them regularly even if your cat appears better,
so excess stomach acid cannot start building up again.
Famotidine (Pepcid AC)
Famotidine (Pepcid
AC) is a popular treatment in the USA for feline
CKD cats. It seems to be an effective
treatment, though there are very few studies into
the use of famotidine in cats, particularly CKD cats, and recent studies
are questioning its effectiveness. One such study,
Evaluation of the effect of orally administered acid
suppressants on intragastric pH in cats (2015)
Parkinson S, Tolbert K, Messenger K, Odunayo
A, Brand M, Davidson G, Peters E, Reed A & Papich MG Journal of
Veterinary Internal Medicine29(1) pp104-112, states "These
results suggest that both omeprazole formulations provide superior acid
suppression in cats compared to famotidine or placebo" but this small
study was conducted in healthy cats. Many people do report that famotidine
does seem to help their cat feel better so I would talk to your vet about
trying it.
Famotidine is available as a generic or, in the USA, under the brand name Pepcid AC. Famotidine may be sold under a
different name in your country (e.g. Amfamox, Famox or Pepcidine in New Zealand and
Australia).
General Medical shows which trade names famotidine is known by in
various
countries. Famotidine is available in the USA as a tablet, oral suspension
or as an injectable.
Famotidine Tablets
USA
Pepcid AC (Regular Strength) in the USA contains 10mg
of famotidine.
If you opt for the brand name, there are
quite a few Pepcid products available so make sure you buy the correct one. You need Pepcid
AC 10mg but not the chewable type, and not Pepcid Complete, both of which have some ingredients which make them unsuitable for
CKD
cats. There is also a new version called Pepcid Maximum Strength, which is
the same as Pepcid AC except that it contains twice as much famotidine, so
be very sure you have the correct strength (10mg tablets).
Using generic famotidine is acceptable, but make sure it is
the correct strength and that it does not contain any additional
ingredients.
Sells 90 10mg tablets under the Equate brand for US$7.88
UK
Pepcid AC has been discontinued in the UK and
replaced by PepcidTwo. PepcidTwo contains magnesium and calcium in
addition to famotidine, so it is not suitable for CKD cats.
Famotidine does exist in generic form and is available from chemists, but
only in 20mg size, which could be difficult to cut into cat-sized doses; plus it requires a
prescription from your vet.
If you really want
to use famotidine, it is sometimes available from
Amazon UK in the 10mg strength at prices
ranging from £5-65 (search for Pepcid AC or famotidine), though I couldn't
find any when I checked in August 2018.
Sells famotidine in compounded cat-sized tablet form in a 5mg size (so
you only need to cut the pills in half) but your vet has to order it for
you. 100 tablets cost around £16 plus VAT and your vet's mark up.
Sells famotidine in compounded cat-sized form, though they do actually
offer 2.5mg capsules. 90 2.5mg capsules cost £93.79, or 100 5mg tablets
for £46.20, both plus VAT and shipping costs of around £12.50. They also
sell
100ml of
famotidine 2.5mg per ml for £91.89, with a 90 day expiry from manufacture.
If you don't want to pay those prices, I would
consider using
ranitidine instead.
Famotidine Oral Suspension
Famotidine is also available as an oral suspension (liquid) in the USA. It
is widely available from compounding pharmacies, and usually costs around
US$20 for a month's supply.
Sell a 10mg/ml oral
suspension (liquid) version of famotidine in a 20ml size for US$24.95. If
you want to give the usual famotidine dose of 2.5mg (see below), you would
give 0.25ml, so this product contains 40 doses altogether. This product
has a short shelf life of 30 days (including delivery). If you
enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
Famotidine Injectable
Some people prefer to use this because famotidine tastes very bitter in
pill or oral suspension form. You
can use the injectable either by injecting it directly into your cat, or
if your cat is on sub-Qs, by adding it to the injection port of your IV
line.
There are two types of famotidine injectable. There is a 10mg/ml
strength without preservative, which is available in 2ml vials. Because it
contains no preservatives, this has a short shelf life (it is intended for
single use in humans). There is also a 10mg/ml strength available in
a 20ml
size vial. This contains a preservative and can be re-used, though it
needs to be shipped chilled and should be kept in the fridge after you
receive it. It is safe to take it out of the fridge about 30 minutes before using it so it can
warm up a little before use.
Injectable famotidine is often out of stock so you may have to search for
it.
Sell the 10mg/ml
injectable form of famotidine in a 20ml size for US$19.95 in the USA. If you want to give the
usual famotidine dose of 2.5mg, you would give 0.25ml, thus the 20ml size
contains 80 doses altogether. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
10mg/ml form. A box of 25
bottles of 2ml (50 ml total) costs US$40.
Famotidine Dosages
Famotidine is excreted by the kidneys, and cats with CKD cannot process it
as efficiently as healthy cats, so it may
accumulate in the cat's body and cause problems.
Drug dose adjustments for disease
(2010) Trepanier LA CVC in Washington Proceedings discusses
the need to adjust dosing levels for some medications when diseases
including CKD are present.
Below are suggestions for famotidine dosages for CKD cats, but be guided by
your vet. You should only use famotidine with your
vet's approval. Do not start with the maximum dose, it could be risky.
Starting dose:
2.5 mg once every other day
i.e. quarter of a 10mg tablet once every two days e.g. on Mon, Wed, etc.
Intermediate dose (if starting
dose does not seem to be helping):
2.5mg once
a day
i.e.
quarter of a 10mg tablet once a day
Maximum dose:
2.5mg twice a day
i.e. quarter of a 10mg tablet twice a day, 5mg a day in total
If you are only giving famotidine once a day, I would recommend doing so at bedtime because
this seems to help cats who vomit at night or first thing in the morning. Famotidine tastes quite bitter and can make cats foam at the mouth, so you may find it easier to give it in a
gelatine
capsule (gelcap) or to use the injectable form (see
above). It usually takes effect
pretty quickly, within a couple of days for most cats.
Some people find that after a while, famotidine seems to be less
effective. Evaluating the prolonged use of an antacid,
famotidine, in cats is a study
funded by the Winn Feline Foundation in 2017 which investigated if it
does become ineffective in cats and whether changing the dose might help.
Evaluating the effect of prolonged famotidine
administration in cats (2018) is
the final report on the study which concluded that famotidine does become
less effective over time but that this can be avoided if given every other
day rather than daily.. Alternatively, you could ask your vet about switching
to ranitidine.
Famotidine Side Effects and Interactions
The most common side effects in humans are constipation or diarrhoea.
Some cats, particularly those with high bloodwork
(creatinine over 5 mg/dl (USA) or 450 µmol/L (international)),
do not seem to do well on famotidine, perhaps because their kidneys cannot excrete
it efficiently as described above. These cats may in fact exhibit increased vomiting
and appetite loss when given it - this happened to our
Thomas.
Drugs
mentions how an overdose may cause vomiting. If your cat's vomiting
and appetite loss do not improve after two days of using famotidine,
ask your vet about switching to
ranitidine.
Famotidine may adversely affect cats with existing heart rhythm
problems. In such cases you may wish to ask your vet about using
ranitidine instead.
Medicine Net mentions that famotidine may cause
anaemia in humans.
This does not appear to be a problem in cats given oral famotidine, but
there were rare reports of intravenous famotidine causing haemolytic
anaemia in cats.
Risk of hemolytic anemia with intravenous
administration of famotidine to hospitalized cats
(2008) de Brito Galvao JF & Trepanier LA Journal
of Veterinary Internal Medicine22(2) pp325-9 found that
"the IV route appeared safe when famotidine was administered over 5
minutes."
Web MD
reports that human CKD patients on famotidine may exhibit abnormal levels
of drowsiness.
Chronic kidney disease (CKD) in dogs and cats - staging and management
strategies (2015) Chew D
Presentation to the Virginia Veterinary Medical Association 2015 Virginia
Veterinary Conference states that "Calcium
carbonate binds phosphorous best in an acidic environment (pH approx. 5)
and binding capacity is reduced in the neutral pH range. Many CKD patients
receive inhibitors of gastric acid secretion potentially reducing calcium
carbonates ability to bind phosphorous." I did use calcium-based
binders and famotidine with Ollie with no problems, but if you are using
calcium-based phosphorus binders such as Ipakitine or Pronefra, I would discuss the situation with your vet.
Famotidine can interfere with antibiotics in the
cephalosporin family such as
cefovecin (Convenia), so you should separate the two treatments by two hours.
I am sometimes asked why I mention this when Convenia is an injectable
medication. H2-antagonist cephalosporin interactions
(2003) Ali A Thesis states "These interaction studies with H2-receptor antagonists in
gastric as well as blood pH revealed that simultaneous use of
these drugs depressed the availability of the antibiotic as well
as cimetidine, ranitidine and famotidine." Plumb's
Veterinary Drug Handbook does not mention cefovecin (Convenia)
specifically, but does mention that taking other members of the
cephalosporin family with food may offset the reduced absorption of
the antibiotic.
Famotidine may reduce the absorption of vitamin B12 from
food.
Proton pump inhibitor and histamine H2 receptor
antagonist use and vitamin B12 deficiency
(2013) Lam JR, Schneider JL, Zhao W
& Corley DA Journal of the American Medical Association 310(22)
pp2435-2442 found that in humans "gastric acid inhibitor use was
significantly associated with the presence of vitamin B12 deficiency."
Therefore if you are using famotidine, it might be worth supplementing
vitamin B12.
I used to recommend giving famotidine at least two hours apart from
sucralfate (Carafate
or Antepsin) or
metoclopramide (Reglan), because, according to
Plumb's Veterinary Drug Handbook, these other medications could bind
with the famotidine and thereby reduce its effectiveness. However, the
most recent edition of Plumb's does not mention this requirement, so it
appears that you do not need to separate famotidine from these other
medications after all.
RX Med states that "concomitant use of
aluminum hydroxide/magnesium hydroxide at commonly used doses, does not
influence the pharmacodynamics or bioavailability of Pepcid AC." Plumb's does still recommend separating famotidine from
phosphorus
binders and
ACE inhibitors. I would try to err on the side of caution and still separate
famotidine from phosphorus binders and ACE inhibitors if you can, but if
this is difficult for you, e.g. because of work commitments, just do the
best you can.
Veterinary Partner has more
information on famotidine, and mentions how it may adversely affect cats
with heart rhythm problems.
Another popular over the counter histamine H2 antagonist is ranitidine (trade name is Zantac 75),
which
works in a similar way to famotidine. Some people prefer to use
ranitidine, especially if their cat has experienced increased vomiting with
famotidine, as happens with a small number of cats (usually those with
creatinine over 5 mg/dl USA or 450 µmol/L international).
Ranitidine tablets are widely available, either as a generic or under the
trade name Zantac 75 (because these tablets are a 75mg size).
The main problem with ranitidine tablets is dividing them into cat-sized
dosages - they usually have to be cut into eighths (assuming you are using
the 75mg size). If you find it hard to cut the pill into eight, you could try
dissolving it in water and giving an eighth of the resulting mixture via
syringe.
USA
In the USA they cost around US$20 for 80 75mg
tablets.
Zantac OTC has regular coupons available.
UK
In the UK ranitidine usually costs around £1.20 for 12 75 mg tablets.
Many people like to buy the branded product, Zantac 75, but generic
ranitidine is widely available, though be sure to check the
ingredients before using because many of these products seem to contain
additional ingredients, not all of which may be appropriate for cats.
If you would prefer not to have to cut the tablets yourself,
Summit Veterinary
Pharmaceuticals sells ranitidine
in compounded cat-sized tablet form in 5mg and 10 mg sizes, though your
vet would have to order these for you. 100 tablets cost around £15 (5mg)
to £18 (10mg) for 100, plus VAT and your vet's mark up.
Australia
Unfortunately
in Australia it appears the smallest size available is now 150 mg, which
is very difficult to divide into cat-sized doses, though you may be able
to use a compounding pharmacy.
Ranitidine Oral Suspension
There is also a liquid (syrup) form of ranitidine in the USA, but this is
peppermint flavoured, so not many cats would like it, plus you need a
prescription for it. However, I understand you can obtain it in a beef
flavoured compounded suspension from
Thriving Pets. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
Ranitidine Injectable
There is also a prescription only injectable form of ranitidine obtainable from
most US pharmacies (they may need to order it for you, and it seems to go
out of stock quite regularly in recent times). As of April 2017 it seems
to be back in stock in theory but is now extremely expensive (around US$50
per vial) and can still be hard to track down.
Injectable ranitidine comes in a 25mg/ml strength, usually in a 6ml vial.
You can either inject this directly into your cat, or if your cat is
on sub-Qs, add it to the injection port of your IV line. A possible
dose is 0.3ml twice a day, but ask your vet. Injectable ranitidine usually
needs to be refrigerated but it is safe to take it out about 30 minutes
before using it so it can warm up a little before use.
Thriving Pets sells injectable ranitidine. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
Ranitidine Dosages
One reason why people may decide not to use ranitidine is that it usually
has to be given twice a day, whereas famotidine is usually only given once
every other day, or occasionally once a day.
The usual dose is 0.25 to 1.00 mg per pound (0.5 - 2.00 mg per kg) every
8-12 hours, though most people find twice a day is fine.
You therefore would give a 10lb (4.5kg) cat 2.5 - 10 mg twice a day.
The standard size pill is 75mg, so for a
10 lb (4.5kg) cat who is getting the higher dose, it is usually easiest
simply to give an eighth of a tablet twice a day (i.e. 9.375 mg, or a
little under 10 mg).
Some people give up to twice this amount, but as with famotidine,
I suggest starting low and increasing the dose if necessary since
ranitidine
is also excreted by the kidneys. Be guided by your vet.
The effect of orally administered ranitidine and
once-daily or twice-daily orally administered omeprazole on on
intragastric pH in cats (2015) Šutalo S,
Ruetten M, Hartnack S, Reusch CE & Kook PH Journal of Veterinary
Internal Medicine 29(3) pp840-6 used a dosage of 1.5-2.3 mg/kg
twice a day. This equates to 6.75 - 10.35 mg twice a day for a 10 lb
(4.5kg) cat. However, the study concluded "standard dosages of ranitidine
were not effective acid suppressants in cats." Nevertheless, I do hear
from people who find ranitidine effective, so discuss the best approach
for your cat with your vet.
Ranitidine tastes quite bitter and can make cats foam at the mouth, so you may find it easier to give it in a
gelatine
capsule (gelcap).
Many people prefer to give the second dose of the day at bedtime because this seems to help cats who
vomit at night or first thing in the morning. It usually takes effect
pretty quickly, within a couple of days.
As with famotidine, some people find that after a while, ranitidine seems
to be less effective. Speak to your vet about either increasing the dose
or frequency or using another treatment as well as or instead of the
ranitidine.
Ranitidine Side Effects and Interactions
Ranitidine may cause vomiting and diarrhoea in some cats.
Chronic kidney disease (CKD) in dogs and cats - staging and management
strategies (2015) Chew D
Presentation to the Virginia Veterinary Medical Association 2015 Virginia
Veterinary Conference states that "Calcium
carbonate binds phosphorous [sic] best in an acidic environment (pH approx. 5)
and binding capacity is reduced in the neutral pH range. Many CKD patients
receive inhibitors of gastric acid secretion potentially reducing calcium
carbonates ability to bind phosphorous." I did use calcium-based
binders and famotidine with Ollie with no problems, but if you are using
ranitidine in addition to
calcium-based phosphorus binders such as Ipakitine or Pronefra, I would discuss the situation with your vet.
Ranitidine can interfere with antibiotics in the
cephalosporin family such as
cefovecin (Convenia), so you should separate the two treatments by two hours.
H2-antagonist cephalosporin interactions
(2003) Ali A Thesis states "These interaction studies with H2-receptor antagonists in
gastric as well as blood pH revealed that simultaneous use of
these drugs depressed the availability of the antibiotic as well
as cimetidine, ranitidine and famotidine." Plumb's
Veterinary Drug Handbook does not mention cefovecin (Convenia)
specifically, but does mention that taking other members of the
cephalosporin family with food may offset the reduced absorption of
the antibiotic.
Ranitidine may reduce the
absorption of vitamin B12 from food.
Proton pump inhibitor and histamine H2 receptor
antagonist use and vitamin B12 deficiency
(2013) Lam JR, Schneider JL, Zhao W & Corley DA Journal of the American Medical Association 310(22)
pp2435-2442 found that in humans "gastric acid inhibitor use was
significantly associated with the presence of vitamin B12 deficiency."
Therefore if you are using ranitidine, it might be worth supplementing
vitamin B12.
It is also advisable to separate ranitidine from
ACE inhibitors
such as benazepril (Fortekor), but if this is difficult for you, e.g. because of work
commitments, just do the best you can.
You may be offered another drug in this family called cimetidine.
Cimetidine has many more drug interactions than either famotidine
or ranitidine, including with
amlodipine (a calcium channel blocker used to treat
heart disease or high blood pressure), and
diazepam (Valium), which is
sometimes used as an appetite stimulant. It also has the most marked
rebound effect (a temporary increase in stomach acid) if it is stopped.
I would therefore suggest using famotidine or ranitidine instead.
Chronic kidney disease (CKD) in dogs and cats - staging and management
strategies (2015) Chew D
Presentation to the Virginia Veterinary Medical Association 2015 Virginia
Veterinary Conference states that "Calcium
carbonate binds phosphorous [sic] best in an acidic environment (pH approx. 5)
and binding capacity is reduced in the neutral pH range. Many CKD patients
receive inhibitors of gastric acid secretion potentially reducing calcium
carbonates ability to bind phosphorous." I did use calcium-based
binders and famotidine with Ollie with no problems, but if you are using
cimetidine in addition to
calcium-based phosphorus binders such as Ipakitine or Pronefra, I would discuss the situation with your vet.
Cimetidine can interfere with antibiotics in the
cephalosporin family such as
cefovecin (Convenia), so you should separate the two treatments by two hours.
H2-antagonist cephalosporin interactions
(2003) Ali A Thesis states "These interaction studies with H2-receptor antagonists in
gastric as well as blood pH revealed that simultaneous use of
these drugs depressed the availability of the antibiotic as well
as cimetidine, ranitidine and famotidine."
Cimetidine may reduce the absorption of vitamin B12 from food.
Proton pump inhibitor and histamine H2 receptor
antagonist use and vitamin B12 deficiency
(2013) Lam JR, Schneider JL, Zhao W & Corley DA Journal of the American Medical Association 310(22)
pp2435-2442 found that in humans "gastric acid inhibitor use was
significantly associated with the presence of vitamin B12 deficiency."
Therefore if you are using cimetidine, it might be worth supplementing
vitamin B12.
Top ten potential drug interactions on dogs and cats
(2008) Trepanier LA Presentation to the World Small Animal Veterinary
Association World Congress recommends using famotidine or ranitidine
rather than cimetidine.
Pet Place has information about
cimetidine (no need to register to read the article, just click on Close at
the bottom of the pop-up).
Omeprazole (Prilosec,
Losec)
Omeprazole belongs to a family of drugs known as proton pump inhibitors
(PPIs). These medicines are not acid blockers like famotidine (Pepcid),
which block acid after it has been produced, but instead work by inhibiting
the release of acid into the stomach in the first place. They are
therefore often used for the treatment of stomach ulcers, but are also
increasingly being used to help CKD cats.
Antisecretor activity of omeprazole in the conscious
gastric fistula cat: comparison with famotidine
(1989) Coruzzi G & Bertaccini G Pharmacological Research
21(5) pp499-506 found that omeprazole was "approximately fivefold less
potent than famotidine." It found that omeprazole was most effective when
the stomach was at the peak of acid production. However,
Evaluation of the effect of orally administered acid
suppressants on intragastric pH in cats (2015) Parkinson S,
Tolbert K, Messenger K, Odunayo A, Brand M, Davidson G, Peters E, Reed A &
Papich MG Journal of Veterinary Internal Medicine29(1)
pp104-12 found that omeprazole (in both tablet form, and a
reformulated paste form normally used for horses) appeared to be more effective than famotidine.
It also found that omeprazole is "generally well tolerated" in cats.
The International Renal Interest Society
(2015) recommends treating reduced appetite, vomiting or nausea "with
a proton pump inhibitor (e.g., omeprazole) and an
antiemetic (e.g., maropitant or
ondansetron). However, further
investigations are needed on the use of these drugs to determine whether
they are useful for managing gastrointestinal disturbances in cats with
CKD and uraemia."
So why don't I recommend starting with omeprazole rather than the
histamine H2 antagonists, such as famotidine? Well, firstly, because I've
seen the histamine H2 antagonists used for much longer, since 1999, and
most people seem to find they are effective with few side effects.
Secondly, in 2016 a human study,
Proton pump inhibitor use and the risk of chronic
kidney disease (2016)
Lazarus B, Chen Y,
Wilson FP, Sang Y,
Chang AR, Coresh J &
Grams ME Journal of the American Medical
Association Internal Medicine176(2) pp238-246, reviewed the
use of PPIs in humans and found that "Proton pump inhibitor use is
associated with a higher risk of incident CKD." In one study, the risk was
50% higher. I do not know whether IRIS will be revising its guidelines in
light of this study.
Omeprazole is available over the counter in many countries in both tablet
(omeprazole) and slow release capsule (omeprazole magnesium) form. Discuss
which formulation to use with your vet.
Omeprazole Tablets
The tablets usually come in a 20.6mg strength and are supposed to be taken on an empty stomach in the morning,
half an hour before eating.
The tablets are enteric-coated, so are not supposed to be broken up. Plumb's
Veterinary Drug Handbook (7th Edition) says
"Omeprazole capsules or tablets should not be crushed or chewed."
However,
Evaluation of the effect of orally administered acid
suppressants on intragastric pH in cats (2015) Parkinson S,
Tolbert K, Messenger K, Odunayo A, Brand M, Davidson G, Peters E, Reed A &
Papich MG Journal of Veterinary Internal Medicine29(1)
pp104-12 found that if you split the tablets into cat-sized doses,
"enteric-coated omeprazole tables are effective for acid suppression in
spite of the disruption of the enteric coating." Some members of
Tanya's Support Group do use the tablets for their cats (split into
cat-sized doses) and find them
effective.
Drugs has a list of US brands
showing whether they are tablets or capsules.
Walgreens sells 42 tablets in the 20.6mg
strength for US$20.99.
Boots in the UK sells 28 tablets in a
10mg strength for £14.99.
Omeprazole Capsules
The capsules usually come in a 20.6mg strength and contain omeprazole
magnesium. The magnesium helps to make the product delayed release, so it
reaches the stomach intact, where it is needed.
Magnesium is not ideal for CKD cats, but at least
some of the magnesium will be part of the capsule, which you discard.
However, the tiny beads are also coated because they need to reach the
stomach intact.
In
theory the capsules should not be used for cats, because slow release
medicines are not supposed to be opened, but an entire capsule is too big
for a cat. Quite a few members of Tanya's CKD Support Group have
opened and used capsules successfully for their cats. Plumb's Veterinary
Drug Handbook (7th Edition) says
"Omeprazole capsules or tablets should not be crushed or chewed. If
reducing the dose of the commercially available capsules, the capsule
contents should be re-inserted into a gelatin capsule so they cannot be
chewed." However, many people do simply mix the capsule contents with
their cat's food, see
below.
If your vet agrees to you using capsules, you will see that each capsule
contain beads (microspheres). You should open one of the capsules and
count the microspheres. The number varies depending upon the manufacturer.
Once you know how many beads your chosen product contains, you can
calculate your cat's dose. For example, if your 20mg capsule contains 100
beads, and you want to give your cat 2.5mg, you would give your cat 12-13
beads once a day.
Unfortunately many omeprazole capsules have too many beads to count,
especially in the USA). CVS sells its own version of omeprazole capsules,
but members of my support group find they usually contain tiny beads
which seem to carry a lot of static and are therefore very difficult to
count. One group member did count them though, and found there were close
to 3000 beads in one capsule! Walgreens used to sell reasonable capsules
but recently they seem to be a tablet within a capsule. Kroger apparently sells a generic from of omeprazole with not too
many beads, though not everybody has had success in finding them. Altosec generic capsules apparently only contain about twenty
beads.
Drugs has a list of US brands
showing whether they are tablets or capsules.
Vet Rx Direct sells omeprazole capsules
for 31 cents each (10g) and 56 cents (20mg). A member of Tanya's Support
Group tells me these contain countable beads. A prescription is required.
Amazon sells 42 20.6mg strength capsules
for US$27.99.
Omeprazole Compounded
Some people prefer to have omeprazole compounded into capsules or a liquid
for their cats. Plumb's Veterinary Drug Handbook (2011) states "Use
caution when using compounded omeprazole products; bioequivalence has been
an issue with some compounded preparations." Nevertheless, some members of
Tanya's Support Group do use compounded omeprazole without problems.
Omeprazole Dosage
Omeprazole Dosage: Amount
Pet Place states that "The typical dose
administered to animals is 0.25 to 0.5 mg per pound (0.5 to 1.0 mg/kg),
every 24 hours or once daily." Based on the per pound dosage, a 10 lb
(4.5kg) cat would receive 2.5 to 5 mg once a day (which is actually a
little more than 0.5 to 1.0 mg/kg).
Many people on Tanya's CKD Support Group start with a dose of 1 mg/kg per
day, so a 10lb (4.5kg) cat would receive 4.5 mg.
Omeprazole is excreted via the liver and kidneys, so
speak to your vet about a
suitable dose for your cat, especially if your cat has more advanced
kidney disease.
Omeprazole Dosage: Frequency
Previously omeprazole was dosed once daily.
A recent study,
The effect of orally administered ranitidine and
once-daily or twice-daily orally administered omeprazole on
intragastric pH in cats (2015) Šutalo S,
Ruetten M, Hartnack S, Reusch CE & Kook PH Journal of Veterinary
Internal Medicine 29(3) pp840-6, assessed the effectiveness of once daily versus twice daily
dosing and concluded that "twice-daily PO [orally] administered omeprazole
significantly suppressed gastric acidity in healthy cats, whereas
once-daily omeprazole and standard dosages of ranitidine were not
effective acid suppressants in cats."
This study looked at the use of omeprazole in a small group of healthy
cats. Whether the same approach is appropriate for CKD cats is debatable,
bearing in mind that omeprazole is excreted via the liver and kidneys, and
there are other possible side effects and risks (see below).
Nevertheless, in light of this study some members of Tanya's CKD Support
Group have started (with their vets' approval) either increasing their
cat's dose or dividing the total daily dose into two and giving it to
their cats twice a day; in some cases they have done both. Many of those I
hear from think this is helping their cats, but as ever, be guided by your
vet regarding the best approach for your cat.
Omeprazole Dosage: Length of Treatment
The main disadvantage with omeprazole is that in humans, it is used for 14
days only and then not used again for four months. Plumb's Veterinary Drug
Handbook mentions that it is thought to be safe to use omeprazole in dogs
for at least four weeks.
A prospective, placebo-controlled pilot evaluation
of the effect of omeprazole on serum calcium, magnesium, cobalamin,
gastrin concentrations and bone in cats (2016) Gould E,
Clements C, Reed A, Giori L, Steiner JM, Lidbury JA, Suchodolski JS, Brand
M, Moyers T, Emery L & Tolbert MK Journal of Veterinary Internal
Medicine 30(3) pp779-86 found that giving omeprazole to six
healthy cats for eight weeks did not seem to have an adverse effect on the
examined perameters, however, this was a very small study into healthy
cats. Still,
I do know of some people who have used omeprazole on an ongoing basis
with no apparent problems. Be guided by your vet as to the best course of
action for your cat.
Omeprazole: Speed of Response
Some cats respond to omeprazole within a day, but it can take up to a week
to take effect. During this period, or if omeprazole alone
does not seem to be sufficient to help your cat, your vet may ask you to
continue using other treatments.
It is acceptable to use omeprazole at the same time as
famotidine or ranitidine, as long as your vet approves.
Can famotidine and omeprazole be combined on a
once-daily basis? (2007) Fändriks L,
Lönroth H, Pettersson A & Vakil N Scandinavian Journal of
Gastroenterology42(6) pp689-94 found that doing so was safe in
healthy humans, and some members of my support group do the same for their
cats.
Omeprazole: How to Give
Unlike acid blockers such as famotidine (Pepcid), omeprazole is tasteless.
Therefore many people just mix the correct number of beads from the
capsule formulation (see above) with their
cat's food. If you do this, ensure your cat eats the food within 15
minutes. Humans are advised to take omeprazole an hour before food and in
the morning, and Plumb's also recommends giving it before meals, ideally
in the morning. If you are using the tablet form, I would follow this
advice.
Omeprazole Risks
It has been known for some time that the use
of PPIs such as omeprazole has been associated with a higher risk of
acute kidney
injury. In 2016 a human study,
Proton pump inhibitor use and the risk of chronic
kidney disease (2016)
Lazarus B, Chen Y,
Wilson FP, Sang Y,
Chang AR, Coresh J &
Grams ME Journal of the American Medical
Association Internal Medicine176(2) pp238-246
reviewed the use of PPIs in humans and found that "Proton pump
inhibitor use is associated with a higher risk of incident CKD.
Future research should evaluate whether limiting PPI use
reduces the incidence of CKD."
The authors further state "Use of PPIs may lead to
chronic kidney disease through recurrent acute kidney injury or
hypomagnesemia."
The risk was higher when the PPIs were taken twice a day rather than once
a day.
An unexpected effect of proton pump inhibitors:
elevation of the cardiovascular risk factor ADMA
(2013) Ghebremariam YT, LePendu P, Lee JC, Erlanson DA, Slaviero
A, Shah NH, Leiper J & Cooke JP Circulation 128(8) pp845-53
found that proton pump inhibitors may increase the risk of major adverse
cardiovascular events. However, in a later study,
Proton pump inhibitors and vascular function: a
prospective cross-over pilot study
(2015) Vascular Medicine20(4) pp309-316 found that "PPI use [Prevacid] did not
significantly influence vascular endothelial function. Larger, long-term
and blinded trials are needed to mechanistically explain the correlation
between PPI use and adverse clinical outcomes, which has recently been
reported in retrospective cohort studies." I do not know whether the same
risks might exist with cats, but I would double check with your vet before
using omeprazole in a cat with heart problems.
Omeprazole Side Effects
and Interactions
According to Plumb's Veterinary Handbook, possible side effects include
nausea, vomiting and diarrhoea. Urinary tract infections,
proteinuria or central nervous system disturbances may also be seen.
Omeprazole may also cause a low white blood cell count (neutrophils),
though this is rare.
The US Food & Drug Administration
(2011) states that the long term use (usually for more than a year) of
medications such as omeprazole may lead to decreased
magnesium levels in the body which cannot necessarily be corrected
with magnesium supplements
One known problem with proton pump inhibitors is that they may inhibit the
absorption of nutrients from food, particularly Vitamin B12 and calcium. It is
recommended that omeprazole should only be used in humans for eight weeks.
Proton pump inhibitor and histamine H2 receptor
antagonist use and vitamin B12 deficiency
(2013) Lam JR, Schneider JL, Zhao W
& Corley DA Journal of the American Medical Association 310(22)
pp2435-2442 found that in humans "gastric acid inhibitor use was
significantly associated with the presence of vitamin B12 deficiency."
Adverse effects of long-term proton pump inhibitor
therapy (2011) Sheen E & Triadafilopoulos G Digestive
Diseases & Sciences56(4) pp931-50 mentions that long term use
in humans is becoming increasingly common and reviews the possible adverse
effects of long term use. The study concluded that the benefits of longer
term treatment outweigh the risks for most patients, but that elderly or
chronically ill patients "theoretically could be at increased risk from
long-term therapy." Therefore if you use it for any length of time, ask
your vet if you should start or increase a
vitamin B12
supplement.
Retrospective analysis of the effect of
acid-suppressant therapy on clinicopathologic parameters of cats
with chronic kidney disease (2018) Gould E,
Klos J, Price J, Harris T, Vaden S & Tolbert MK Journal of
Feline Medicine and Surgery20(6) pp520-527 looked at
the effects of acid suppressant therapy (acid blockers, proton
pump inhibitors and both combined) in CKD cats. It concludes "A
significant increase in blood sodium concentration (change of
3.12 mmol/l) was found independent of stage in cats receiving
PPI therapy." However, the use of acid blockers did not seem to have any adverse
effect on the progression of the CKD.
If omeprazole is stopped, there may be a rebound effect, i.e. there may
be an increase in stomach acid production that is higher than that before
the treatment was begun. This can last a couple of weeks.
Web MD talks more about this.
Omeprazole Research
The University of Tennessee College of Veterinary Medicine is running a
study into the use of omeprazole in CKD cats. There is more information
about the study
here.
If the natural treatments above don't work, and your cat does not respond
too well to acid blockers such as famotidine, or perhaps shows some
improvement but still vomits fairly frequently, you may need to
consider trying one of these other medications. These medications
primarily treat
nausea and/or vomiting but they work in different ways, so discuss
with your vet whether one of them might be suitable for your cat.
I regularly hear from people whose vets are not familiar with the use of
ondansetron or maropitant in CKD cats and therefore they are
understandably reluctant to prescribe them. In such cases, I would refer
your vet to the
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease (2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine &
Surgery18 pp219-239, which say "Centrally
acting antiemetics such as maropitant, mirtazapine, ondansetron and
dolasetron should be considered for management."
Pharmacologic control of vomiting
(2009) Tams TR CVC in Kansas City Proceedings discusses the use of these medications and others in
cats.
Ondansetron (Zofran)
This drug is commonly used to control vomiting in cats with pancreatitis
or cancer, but many people find it effective for nausea in CKD
cats too. It may also help control pain.
I first heard of somebody using ondansetron for a CKD cat in
2002, but it has not been used routinely in CKD cats until recently,
mainly because it was extremely expensive. Since the generic version became available in the USA, however, it is
slowly becoming quite
popular for use in CKD cats. Trade names include Zofran in the USA, Setronon in Europe and Emeset in the
UK.
Ondansetron works in a different way to metoclopramide below (it
selectively inhibits serotonin 5HT3 receptors), so it does not lower the
seizure threshold as metoclopramide does.
Some people use maropitant
(Cerenia) for vomiting, but since one dosing schedule for maropitant requires that it should not be given for more than five days in a row, they use ondansetron on the
other days.
Some people use another drug in this family, dolasetron (Anzemet), which
only needs to be given once a day, but dolasetron seems to be more commonly used at this time for cats with pancreatitis.
Plumb's Veterinary Drug Handbook mentions that dolasetron should not be
given to patients with certain types of heart problem, and should be used
with caution in cats with
low potassium levels.
Pharmacologic control of vomiting
(2009) Tams TR CVC in Kansas City Proceedings has some
information about dolasetron.
Ondansetron comes in 4mg pills, and a commonly used
dose is 1 mg each day, so one pill contains four doses. The pills are tiny, so can be hard to cut
into quarters.
You can be charged as much as US$6 for a single pill, so you need to shop
around, because it is possible to buy the generic pills much more
cheaply. Costco apparently sell 60 4mg tablets for around US$23. This may
work out even cheaper with a pet medication card (see
Obtaining Supplies Cheaply). Many UK chemists can supply ondansetron with a
prescription from your vet. It is usually much cheaper to buy more pills
at one time.
Sell ondansetron for US$1
per 4mg pill, or 80 cents each if you buy 100. A prescription is required.
If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
UK
In 2017 there was a shortage of generic ondansetron in the UK. It is now
available again, but you may need to search for it.
can sell ondansetron, but since it is a human medication, your first
order has to be made over the phone (Tel. 01582 842096) and a prescription
supplied.
Ondansetron Injectable
There is also an injectable form of ondansetron.
Thriving Pets
sells 2mg/ml in a 20ml vial (forty doses for many cats) for
US$19.95. If you enter
the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
The bottle may say it is for intravenous use, but many
people give injectable ondansetron subcutaneously with no problems.
Unfortunately injectable ondansetron stings a lot, but it may be a good
choice for a cat who is struggling to keep anything down, and it does work
quickly - you should see results within a couple of hours. It can help if
you give some of the fluids before you add the ondansetron.
Zajic LB, Herndon
AK, Sieberg LG, Caress AL, Morgan PK, Hansen RJ, Wittenburg LA, Gustafson
DL & Quimby JM Journal of Feline Medicine and Surgery19(12) pp1245-1248
found that "transdermal application of 4mg ondansetron does not result in
clinically relevant serum concentrations of drug."
Ondansetron Dosages:
Amount and Frequency
Ondansetron
Amount
Ondansetron comes in 4mg pills, and a commonly used dose on Tanya's
Support Group is 1 mg each day,
so one pill contains four doses.
This seems to work well for many CKD cats;
though other dosage recommendations also exist:
Pet Place mentions that the usual dose
for cats is 0.11mg per pound bodyweight every 8-12 hours, i.e. 1.1mg for a
10 lb (4.5kg) cat given 2-3 times a day.
Plumb's Veterinary Drug Handbook mentions an empiric dose of 0.5mg per kg
bodyweight twice daily, so a 10 lb (4.5kg) cat would be given 2.25mg twice
a day.
Ondansetron Frequency
It used to be the case that twice daily administration was recommended.
This is what Plumb's above recommends.
You will note that the Pet Place link above mentions doing every 8-12
hours, i.e. two to three times a day.
Oral, subcutaneous and intravenous pharmacokinetics
of ondansetron in healthy cats (2014) Quimby JM, Lake RC,
Hansen RJ, Lunghofer PJ & Gustafson DL Journal of Veterinary
Pharmacology and Therapeutics37(4) pp348–353
states that "twice daily administration at 0.5 mg/kg is likely inadequate
to maintain serum concentrations within the therapeutic range; higher or
more frequent doses may be needed." However, it further states that "the
postulated therapeutic range - extrapolated from a previously published
pharmacodynamic study - may not be accurate particularly if applied to
repeated administration for chronic disease states."
Ondansetron: Choosing a Dosage
Amount and
Frequency
The study also states that "Poor bioavailability should be taken into
account when determining a route of administration for a patient as
individual oral bioavailability ranged from 11 to 50% in the cats used in
this study."
This means that dosage needs are quite variable, which is probably why
there are quite sizable differences between the doses discussed above.
For acute vomiting, such as in a cat with pancreatitis, higher and/or more
frequent dosing may indeed be necessary. For chronic nausea in CKD cats,
however, many people find the lower dose is fine, though they may need to
give ondansetron twice or even three times daily.
I would start with the lower dose of 1 mg each day, and if you find this
is not enough, speak to your vet about increasing the dose and/or
frequency.
Ondansetron Side Effects and Interactions
Possible side effects include constipation, low blood pressure and sleepiness. Humans have reported bad
headaches.
Drugs has more information about possible
side effects.
It was previously reported that when given intravenously to humans in high
doses, ondansetron may cause heart arrhythmias. In June 2012
The US Food & Drug Administration
reported that "a 32 mg single intravenous dose of ondansetron
(Zofran, ondansetron hydrochloride, and generics) may affect the
electrical activity of the heart (QT interval prolongation), which could
pre-dispose patients to develop an abnormal and potentially fatal heart
rhythm known as Torsades de Pointes." Ondansetron
and the risk of cardiac arrhythmias: a systematic review and postmarketing
analysis (2014) Freedman SB,
Uleryk E, Rumantir M & Finkelstein Y Annals of Emergency Medicine 64(1)
pp19-25 looked into this and concluded "No reports describing an
arrhythmia associated with single oral ondansetron dose administration
were identified." For those apparently affected by intravenous ondansetron
"A significant medical history (67%) or concomitant use of a QT-prolonging
medication (67%) was identified in 83% of reports. Approximately one third
occurred in patients receiving chemotherapeutic agents, many of which are
known to prolong the QT interval. An additional third involved
administration to prevent postoperative vomiting." This is probably not a
concern for most CKD cats, but discuss with your vet if you are worried.
There is some debate as to whether ondansetron causes
serotonin syndrome.
The US Food and Drug Administration
states that it may, though it says that "The majority of reports of
serotonin syndrome related to 5-HT3 receptor antagonist use occurred in a
post-anesthesia care unit or an infusion center." It also says that
serotonin syndrome is more common when given at the same time as
medications such as
mirtazapine (used in CKD cats as an appetite stimulant).
Drugs also mentions that using ondansetron and
mirtazapine together may
increase the risk. However,
Can 5-HT3 antagonists really contribute to serotonin
toxicity? A call for clarity and pharmacological law and order
(2014) Rojas-Fernandez CH Drugs - Real World Outcomes1(1)
pp 3–5 disputes that ondansetron causes serotonin syndrome. Discuss with
your vet whether to give both medications, and if you do so, give them at
least two hours apart.
(2002) Arcioni R,
della Rocca M, Romano S, Romano R, Pietropaoli P & Gasparetto A
Anesthesia and Analgesia94(6) pp1553-7 reports that
ondansetron may reduce the painkilling effects of
tramadol by up to 50% in humans. It is not known if the same applies
to cats.
Maropitant (Cerenia)
Maropitant (Cerenia)
is a relatively new treatment which works by inhibiting
neurokinin (NK) inhibitors. In other words, it works by blocking the
stimulation of the part of the brain that instigates vomiting.
Maropitant: novel antiemetic (2015) Trepanier LA Clinician's BriefFeb 2015
pp75-77 explains more about how it works.
The injectable form is approved for the
treatment of vomiting and nausea in cats (and dogs) in Europe and the USA. In Europe,
injectable maropitant is also approved for travel sickness in
cats.
Treatment for visceral pain with the new NNK-1
receptor antagonist maropitant in cats
(2011) Boscan P, Monnet E, Twedt D & Nyiom S, found that maropitant
may also be an effective painkiller, so it may be a good choice for a
vomiting cat with
pancreatitis.
Some people find
maropitant works better for their cats than ondansetron, so if you are not
finding ondansetron to be as effective as you hoped, I would try
maropitant instead.
Maropitant is available in either injectable or pill form. Both the
injectable and the pill form are intended to prevent vomiting, but the
injectable form is also designed to treat acute vomiting. Only the
injectable form is approved for use in cats, but the pill form is used off
label.
The oral form seems to taste horrible.
The injectable form seems to sting some cats.
Prevomax is an injectable form of
maropitant that was introduced in the UK and Europe in early 2018. It
contains a preservative that is supposed to reduce the pain of injection.
Maropitant Tablets
Maropitant comes in 16mg-sized tablets so most people use these and break
them into suitable sizes for their cat. Be careful that you are not
offered larger size tablets intended for humans.
Sells four 16mg tablets for US$10.59 with free shipping for orders over
US$60 (shipping costs US$7). I have used Valley Vet myself in the past for
other products with no problems.
Unfortunately there is no generic injectable form of maropitant, and
injectable Cerenia costs around US$150 or more per vial. A typical dose would be
4mg daily (0.4 ml), so a 20 ml vial provides 50 doses costing around $3.20
each.
You may be able to get maropitant more cheaply from a compounding
pharmacy.
Injectable maropitant stings very badly, though keeping it in the fridge may help with this.
The new version called Prevomax which was introduced in the UK and Europe
in early 2018 contains a preservative that is supposed to reduce the pain
of injection.
Once opened, the vial should be stored in the fridge anyway.
Drugs states that it will keep for 90
days in the fridge, but that the stopper should not be punctured more than
25 times, so whether you can really get 50 doses from your vial is
debatable.
Sells 10 mg/ml in a 20ml
vial for US$189.95. This provides around 50 doses (depending upon the size
of the cat) costing US$3.20 each. A
prescription is required.
If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$100. Shipping is free for orders over US$100 after the discount.
UK
Prevomax is available in a 20ml vial of 10 mg/ml size. I have not yet
(March 2018) been able to find out the price of Prevomax.
If giving 1mg per kg (2.2lbs) of body weight a day, a 10
lb cat (4.5 kg) cat would receive 4.5 mg a day.
Most people seem to buy the 16mg size and divide it as appropriate
(into quarters for a 10 lb cat).
If this dosage does not seem to be sufficient, speak to your vet about
increasing the dose, because some cats need up to double this dose, i.e.
to give 2mg per kg (2.2lbs) a day. Many vets seem concerned that this
might be too high a dose, but it is recommended by
ISFM consensus guidelines on the diagnosis and
management of feline chronic kidney disease (2016)
Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I,
Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine
and
Surgery18 pp219-239, which state "2 mg/kg q24h [once a
day]." In this case, a 10lb (4.5kg) cat would receive 9 mg a day.
Oral maropitant is famous for tasting horrible, even if you try to use a
flavoured variety. Unfortunately the pills should not be given in
Pill
Pockets or mixed with food as this may stop them being properly
absorbed in the cat's body, but some people do give them this way. Many
people place the medication in a gelcap in order to hide the taste.
The European Medicines Agency
states that halved tablets should be stored in the foil
they came in and that the shelf life of halved tablets is only two days. I
have not yet heard from anybody who throws away the last half or quarter
of their tablets, but if you think your cat's response to maropitant seems
to be inconsistent (e.g. your cat vomits every fourth day), this might
explain why.
"once daily under the skin (1ml per 10 kg bodyweight) for up to five
days."
Since the injectable form is 10mg/ml strength, this means that the
standard dosage is 1mg per kg bodyweight, the same as the oral dosage.
Therefore a 10 lb (4.5kg) cat would receive 4.5mg a day, or 0.45 ml.
Plumb's Veterinary Drug Handbook states that
0.5 to 1 mg per kg bodyweight can be given for up to five days.
This would mean that a 10 lb (4.5kg) cat would receive 2.25-5.00 mg a day,
or 0.225-0..5ml a day.
The injectable form seems to sting some cats, though keeping it in the
fridge before use, and injecting it into the fluids lump after giving
sub-Qs may make it sting less.
The manufacturer used to recommend that maropitant should only be given short
term to dogs, for a maximum of five days at a time.
Off label use of drugs in veterinary medicine
(2013) Coates J explains that using maropitant for longer can reduce
dopamine levels in the central nervous system and lead to tremors.
In 2015, the
manufacturer announced that the FDA had
approved a change in the labelling of maropitant in tablet form to allow
for it to be given once daily to dogs over the age of seven months until
the vomiting is resolved. The recommendation for dogs aged between two and
seven months remains at a maximum of five days at a time.
In the manufacturer's study into the use of injectable maropitant in cats,
the maropitant was only given for five days. As far as I am aware, the
manufacturer has not assessed maropitant when given daily to cats for
longer periods, whether injectable or in tablet form. Therefore most
people giving maropitant to their cats used to err on the side of caution
and would give maropitant for up to five days,
take a break, then use it again. Plumb's Veterinary Drug Handbook
mentions that the medication should be stopped for at least 48 hours in
these circumstances.
Be
guided by your vet on the best approach for your cat, and monitor your cat
closely for tremors or shaking.
Maropitant Side Effects and Interactions
Possible side effects include vomiting, lethargy, diarrhoea, anorexia, twitching and
drooling. Maropitant should not be used if there is any
gastrointestinal obstruction, and should be used with caution if liver or
heart problems are present (it may increase the risk of arrhythmias).
Drugs has
more information.
The European Medicines Agency
says "Since maropitant could affect heart activity, Cerenia should
be used with caution in animals with certain heart conditions." I do not
know which heart conditions this is referring to, but check with your vet
if your cat has any kind of heart condition.
The European Medicines Agency also says
(clause 4.8 on page 9) that "Cerenia should not be used concomitantly
with Ca-channel antagonists as maropitant has affinity to Ca-channels."
The University of Zürich Institute for Veterinary
Pharmacology and Toxicology also
mentions this (in German). In principle this means that maropitant should not be used with calcium channel
blockers such as
amlodipine (Norvasc or Istin, commonly used to treat high blood
pressure in CKD cats).
'Concomitantly' has a rather vague medical
meaning in that it means during the same time period, but in this context
I don't know exactly what time period the EMA is referring to, i.e. do
they mean at the same time or on the same day? Both of these medications
tend to be given once daily, so they have a relatively long effect. I
suspect that giving them both on the same day but 12 hours apart (i.e. one
in the morning and one in the evening) would probably be acceptable, but
check with your vet.
Cerenia information sheet (tablets)
mentions that maropitant should only be given for five days. It also
states that maropitant may interact with phenobarbital, used to control
epilepsy, and
NSAIDs.
Metoclopramide is a prescription only medication which works by regulating
stomach contractions. This means it can help with nausea caused by a lack
of motility in the stomach.
Pet Place has some information about
gastric motility problems in cats.
Since metoclopramide can cross the blood/brain barrier, it also acts on
the brain to control feelings of nausea. However, it appears that it is
not actually particularly effective in cats.
Current approaches to vomiting in cats and puppies
(2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd
K Pfizer Roundtable Discussion states "I
don’t use metoclopramide in cats anymore. I am not completely convinced it
is that effective as an antiemetic
in cats. Evidence suggests that cats don’t have dopamine receptors in the
chemoreceptor trigger zone, which
is metoclopramide’s site of action."
When I first set up this website in 2000, quite a few people used
metoclopramide for their cats if the histamine H2 antagonists were not
sufficient. I do not recall there being too many problems with the
medication over subsequent years. In 2009, the
US Food and Drug Administration issued a warning regarding the
chronic use of metoclopramide because this had been linked to a condition called tardive
dyskinesia, i.e. involuntary and repetitive movements of the body, which
may continue even after the treatment is stopped. One such movement
mentioned by the FDA is
lipsmacking (although it should be noted that lipsmacking in
CKD cats
is normally caused by excess stomach acid or nausea,
anaemia
or
dehydration).
The FDA therefore recommends that products containing metoclopramide
should not be used for longer than three months.
In July 2013 the
European Medicines Agency went further
and announced that metoclopramide should only be used short term (up to
five days) and that it should only be used in adults "for the
prevention and treatment of nausea and vomiting such as that associated
with chemotherapy, radiotherapy, surgery and in the management of
migraine." In addition, it recommended that dosages should be lowered.
Obviously these
warnings apply to humans, but since there are now other treatments
available as outlined above which are far more effective and carry fewer risks, I would only use
metoclopramide as a last resort. Be sure to discuss these warnings with
your vet before using metoclopramide.
Metoclopramide Dosages
Metoclopramide comes in
10 and 5mg tablets or a liquid. Injectable metoclopramide is also
available as 5mg/ml in 2 ml or 10 ml vials. It must be
given 20-30 minutes before eating.
A typical dose would be 0.1 to 0.2 mg per pound (0.2 to 0.5 mg per kg)
every six to eight hours, so a 10lb (4.5kg) cat would get 1 mg to 2 mg at
a time. Plumb's Veterinary Drug Handbook mentions that dosages may need to
be reduced in animals with kidney disease, so be guided by your vet.
Metoclopramide Side Effects and Interactions
Please see the important warning above.
Metoclopramide may have various side effects,
including constipation, hyperactivity and agitation or drowsiness; very
occasionally, twitching may be seen.
Metoclopramide also lowers the seizure
threshold, so should not be given to cats prone to
seizures.
Drugs mentions that it may increase the risk of bronchospasm in asthmatics, and
intravenous metoclopramide may worsen hypertension (high blood pressure).
I used to recommend giving metoclopramide at least two hours apart from
famotidine (Pepcid AC) or
ranitidine (Zantac 75)
because, according to
Plumb's Veterinary Drug Handbook,
the metoclopramide could bind with these other medications and reduce
their effectiveness. However, the most recent edition of Plumb's does not
mention this interaction, so it appears that you do not need to separate
metoclopramide from these other medications after all.
Using metoclopramide as well as
mirtazapine (appetite stimulant) increases the risk of serotonin
syndrome. You can read more about this and what to watch for
here.
Drs Foster and Smith
have some information about possible side effects. They also
mention that metoclopramide is similar to PABA, the sunscreen component,
so people who are allergic to PABA should not touch metoclopramide.
Please do not use Pepto-Bismol. It contains a type of salicylate,
similar to what is found in aspirin, and cats are not able to metabolise
this easily, so it may be fatal even in small doses.
Pet Place warns against using
Pepto-Bismol in cats.
Antacids
Some vets recommend the use of antacids, such as Tums or Mylanta. Some
products in this family do actually work well in CKD cats as
phosphorus binders,
but they are not usually strong enough to help control excess stomach acid, plus
using products containing
magnesium is not usually recommended for CKD
cats, who tend to have high levels of magnesium generally.
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.
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 on my part. 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.
