*** WARNING: VERY LONG POST ALERT ***
Is there any course of action i can take in the beginning stages of an attack that can prevent her ending up in hospital?
(((Deb)))
It is possible that, in addition to the acute flares, Maggie may possibly have chronic pancreatitis in which case the symptoms may be 'low grade' for much of the time. Kitties with chronic pancreatitis can be prone to flare-ups where symptoms become more severe. If this is the case then yes, there are many things you can do to manage the condition at home - including things that may reduce the likelihood of Maggie needing hospitalisation (depends on the cat and the severity of the flare, but ***early intervention at home can
really help*** and stop a potentially more serious flare in its tracks).
I found the following key to management of the condition at home (sorry it's so lengthy, but I hope it will be helpful to you going forward):
* A close, very collaborative, partnership with the vet. When in doubt, always take your kitty for an examination - especially when signs of discomfort, nausea, poor appetite, or constipation emerge or get worse. If your cat is a veterinary 'frequent flyer' then, between visits to their offices, your vet may be able to help you a lot by telephone (thus saving the stress/cost of an office visit). I always checked in with my vet by phone any time I suspected Saoirse's symptoms were reappearing, plus he had access to her spreadsheets (see below for example).
* Key Clinical warning signs to watch for include: lethargy (the most common symptom exhibited by cats with pancreatitis); symptoms of nausea/digestive discomfort (see list of nausea symptoms in link below); and change in stool quality. Sometimes a cat with pancreatitis may crouch in a tense 'meatloaf' position - especially after a meal - or it may exhibit uncharacteristic vocalisation. Reduced sociability, withdrawal, or hiding behaviours can also alert you to possible GI system distress. Body temperature is another thing to note, as some pancreatitis kitties may exhibit hypothermia (watch for signs that they may be 'feeling the cold'). Know Thy Cat.
I adapted Saoirse's spreadsheet to help me keep track of my observations plus her food and meds. It helped me spot trends in her clinical signs much more easily. Also it helped me to identify foods/meds that did or didn't help her (and it makes it easier to backtrack to something that was working better after any changes have been introduced. Here's a link:
Saoirse 2015 Spreadsheet
Any changes to diet or meds were normally made one at a time, and always slowly.
* Keep watch on how the cat responds to food - even if no diet change has been made. Sometimes a particular batch of the kitty's regular food may disagree with the cat (as a natural product, 100% control of ingredient mix and quality is impossible). Treatment with anti-nausea meds and a switch to a different batch of the food may help resolve symptoms quickly. Here's a very helpful guide to spotting clinical signs of nausea:
Nausea and Appetite Problems - Symptoms and Treatments
* Feeding mini-meals throughout the day (once every 3 hours in Saoirse's case) with a little water added to help keep kitty properly hydrated (very important for pancreatitis kitties. (For info, Saoirse was on Lantus insulin which makes mini-meal feeding quite straightforward. Had she been on an insulin that required a large meal to be fed prior to dose admin (e.g. Caninsulin/Vetsulin), this would have complicated her pancreatitis management.) A timed feeder is an invaluable aid when feeding mini meals. Note: if the flare is particularly severe it may be necessary to assist feed smaller, more frequent feeds during the peak period.
ETA: Raising food and water bowls a few inches from the ground can make it much more comfortable for a nauseated kitty to eat and drink.
I found that, through adding a couple of teaspoons of water to each of Saoirse's meals I was able to keep her properly hydrated without the need for subcutaneous fluids at home. (Home sub-q fluid admin does not appear to be as prevalent in the UK as it is on the North American continent.) If Maggie were to need home sub-q treatment there are many experienced caregivers here who can help you with that. Many cats get on just fine with the treatment, and it does them a world of good. (It makes a huge difference to quality of life for CKD kitties, for example.)
*
ALWAYS, ALWAYS, ALWAYS keep a supply of anti-nausea and appetite stimulant meds always available at home so that treatment for any nausea or mild inappetence can begin
straight away at the first sign of a problem. It is far easier - and better for the kitty - to keep a queasy cat eating than to get a completely inappetent cat to start eating again. It also reduces the risk of fatty deposits building up in the liver (and increasing risk of development of hepatic lipidosis). Lack of food in a diabetic cat may lead to the cat building up ketones which then creates a risk that the cat could go into DKA.
I used generic ondansetron (branded version is Zofran -
way,
way more expensive) for pancreatitis-related nausea management and, occasionally, an appetite stimulant. (Manage the nausea promptly and usually the kitty's appetite will stay OK.) For members in the UK reading this, the Bristol Laboratories ondansetron generic may be less likely to constipate a cat than other generics on the market.
I used cyproheptadine for appetite stimulation. Saoirse only received mirtazapine once, and the side effects she exhibited weren't at all at all pretty (
crazed with hunger; very aggressive; pupils dilated to the size of dinner plates; highly agitated; therapeutic effect petered out long before next dose could be given). That said, many cats get on great with mirtazapine (although they often get very vocal - it's nicknamed 'miaowzapine' for this reason!). I found that cyproheptadine did the job required but it was milder in effect and of shorter duration of action than mirtazapine (can be administered every eight hours if required). I found that cypro gives better control over the level of appetite stimulation provided to a kitty and it has a far more acceptable side effect profile. It's an antihistamine and may cause drowsiness. The idea is to give 'just enough' for the appetite stimulant effect to work. In the home situation it helps to start at a low dose - just a sliver of a tablet - and work upwards: too big a dose can make the cat a bit depressed and it may then become less inclined to eat (counterproductive!). At the right dose there might be a little drowsiness after the dose is administrated but I found that the snoozies wore off after about an hour and the stimulant effect then kicked in. If the low dose is ineffective you can titrate the dose upwards (with guidance from your vet, of course!).
VET NOTE I: When examining a cat to determine possible cause(s) of nausea/inappetence, I've found that vets don't typically check whether the cat might be constipated so it's advisable to to ask the vet to do so at the start of the physical examination. Knowing your cat's regular stool production will help you to identify if constipation might be an issue and it's really helpful information for your vet, too. It's important to address any constipation/gut motility problems first otherwise regular anti-nausea/appy stimulant meds won't be effective (more on this below).
VET NOTE II: We've seen here that a significant number of vets will insist that there is no need to prescribe additional anti-nausea medication when they prescribe mirtazapine. For a seriously nauseated cat, any anti-nausea effect that mirtazapine may exert is typically insufficient to help the cat overcome its eating difficulties. (It's certainly typical of what we see here in pancreatitis and DKA cats.) It can sometimes take a bit of persistence with the vet (or sometimes consultation with another vet) in order to secure additional, dedicated anti-nausea treatment. If a cat can't get any food down it is a life-threatening situation so if the cat still shows symptoms of nausea on mirtazapine alone don't delay going back to the vet to secure an Rx for specific anti-nausea meds. If the vet insists that mirtazapine alone has worked for all his other patients be clear and firm that success it's not working for
your cat and you want something done about it. (The IDEXX document linked below may be very helpful in supporting your case in such circumstances.)
MEDICATION SAFETY WARNINGS: In some cats there can be a major adverse reaction to mirtazapine if they are being simultaneously treated with buprenorphine for pain. Mirtazapine can induce serotonin syndrome (check online for symptoms); potentially life-threatening but prompt emergency treatment with cyproheptadine can normalise serotonin levels. Note: Cyproheptadine may be contraindicated in a cat with liver problems. Also, as an antihistamine, cyproheptadine can raise blood pressure so it may be contraindicated in cats with elevated blood pressure levels (e.g. those with renal impairment). Cyproheptadine is contraindicated in cats with glaucoma. More information
here.
* Pain Management: A pancreatitis kitty may experience pain during a flare. Physical examination of the kitty may show abdominal pain BUT also watch out for back pain, too. Back pain may be misdiagnosed as joint pain/arthritis by a vet not very familiar with pancreatitis symptoms (happened to us, but thankfully there's the internet so I knew it was flare-related!
) NB: If visiting the vet during the acute stage of a flare it may be beneficial to ask for the first dose of bupe to be given via injection as it gets to work faster. Subsequent doses can be administered orally at home.
As mentioned above, crouching/withdrawal/hiding behaviours can indicate that pain is present. Pain tends to be worse during a flare. Pain can be managed with buprenorphine - and effective pain control can help a kitty to get back to eating better more quickly. If in doubt, it's a good idea to ask your vet to treat 'as if' pain is present - possibly with a relatively low dose of bupe at first (it can always be titrated upwards if necessary). A feline internal medicine specialist advised me that giving buprenorphine to ensure any occult pain present during a flare is addressed will reduce systemic stress in the cat and this can help reduce inflammation, potentially resolving the flare faster. Reduction in crouching/hiding and improved appetite and sociability can be good signs to watch for to assess the benefit of the analgaesic treatment.
IMPORTANT NOTE: If a kitty has been on buprenorphine for a while then it may be highly advisable to gradually titrate the dose down before discontinuing treatment. (Cessation of buprenorphine treatment in humans can cause dangerous spikes in blood pressure. I've not seen any research to show similar in cats but based on my own experience I have my suspicions that too-abrupt cessation of bupe treatment caused blood pressure problems in Saoirse which subsequently cost her one of her beautiful eyes ...
Wouldn't wish that on any cat or person. Our main vet gave me a fair hearing when I proposed this hypothesis, but he couldn't add anything.)
SAFETY NOTE: Because it's a controlled substance, some vets may be reluctant to prescribe sufficient buprenorphine for home care and may instead prescribe Tramadol for pain relief . NB: in humans there is a MAJOR adverse interaction between Tramadol and ondansetron. I've not found anything in my research to confirm/deny that a similar problem might occur in cats but personally I would not risk treating a cat of mine with these meds simultaneously. (Other members may have different views/experiences.)
(For UK readers following this thread: Buprenorphine (aka Vetergesic) availability is extremely tightly controlled in the UK. If you do need a supply for home admin ask your vet to dispense a supply of pre-filled syringes (you may need to get repeat Rx's every few days). Keeping brief daily journal notes of dose admin times and response to treatment can be an invaluable evidence base to present to your vet in order to secure repeat Rxs for longer-term pain management if it's needed. (It took a while but my vets (who had access to Saoirse's spreadsheets) were eventually comfortable enough to OK to issue repeat Rxs for prefilled syringes to last 1-2 weeks for ad hoc pain management at home.))
*
Severe Nausea/Inappetence that doesn't respond to meds/pain relief: If the above meds don't get a kitty eating better within a day or two (including situations where you've needed to assist feed to keep getting food into the kitty) it is advisable to go back to the vet quickly and ask about feeding tubes. They make assisted feeding at home much more reliable and less stressful for both cat and caregiver and they can save lives. Feeding tubes also make insulin administration for feline diabetics easier and safer (and help protect the cat from complications like ketosis/DKA). If a feeding tube is indicated it is better not to delay in getting one placed. More information here:
Feeding Tubes for Cats
* Regularly monitor stool quality and frequency. Sometimes constipation can make matters worse. Constipation can cause a cat to be nauseated/to vomit, and it can make a kitty very lethargic. (I introduced canned plain pumpkin to Saoirse's diet and this helped to keep her regular and her stools were more yielding and easier to pass.) On occasion I had to treat her with Miralax and, if meds/anaesthetics had affected her gut motility, brief treatment with metoclopramide (see IDEXX link below for more info on this drug) to get things moving again - typically only a couple of doses - followed by a switch back to her regular anti-nausea treatment. Looser, smellier stools than usual can sometimes (though not always) be a an alert that a pancreatitis flare may be imminent, as can a change in colour to orangey brown or tan. If so, closer monitoring of clinical signs is important. More information on feline constipation and overall gut function and health at the following site:
felineconstipation.org
* Antibiotics: If diarrhoea is a problem during a flare, the vet may prescribe the antibiotic, Flagyl (metronidazole), which is apparently utterly foul-tasting. (Our vet prescribed Stomorgyl 2 for Saoirse. It contains metronidazole plus A. N. Other antibiotic but apparently it's not as foul-tasting.) Vets may also prescribe other antibiotics during a flare as a precautionary measure to protect against infection. Injected antibiotics may be preferable since tablet forms could potentially make GI upset worse. (Note: Many vets prescribe Convenia and this is unlikely to be of much benefit as it is labelled for use in the treatment of skin infections. See
Lisa Pierson DVM's article on Convenia for further info.)
* Maintenance Diet Choice: On food, I found this to be
far and away the toughest challenge when managing Saoirse's chronic pancreatitis. It took
months and months of trialling different foods find what she could eat reliably and with minimum to no discomfort at mealtimes. With an otherwise healthy kitty, food changes need to go slowly to avoid triggering GI upsets and I found this to be even harder with chronic pancreatitis in the mix. It's not that Saoirse found the different foods unappealling; she just couldn't tolerate them.
Sometimes you may find that a kitty readily eats some of the new food but then pancreatitis symptoms get worse after the meal and they won't touch another mouthful of it ever again. Sometimes a bit of anti-nausea support can help with the transition but I learned to follow Saoirse's lead and didn't persist with any food option that caused exacerbation of nausea or postprandial discomfort.
As mentioned above, a food variety that is normally tolerated well may all of a sudden start causing issues (usually increased nausea). Experience taught me to record food batch numbers in Saoirse's daily journal and that helped me to avoid feeding 'problem batches' thereafter. One thing I found extremely helpful was to set aside a 'squirrel stock' of food pouches from batches that I knew really agreed with Saoirse so that I would have something in the house that she could eat comfortably just in case we hit an 'iffy' batch of her regular food. Also, if regular food is badged as a 'new, improved recipe!' (yeah, right ...
) it's important to check the nutritional analysis for any changes. Indeed, sometimes manufacturers change formulations without highlighting it at all so I started regularly double-checking the nutritional analysis of Saoirse's maintenance food as a matter of course.
Some pancreatitis kitties are more sensitive to the fat content of food. There's a feline pancreatitis support group on Yahoo and members there may be able to give you more information and support. Here's a link:
Yahoo Feline Pancreatitis Support Group
* Anti-inflammatory support: Vitamin B12 is good for all cats with any health issues that give rise to nutrient malabsorption plus it has anti-inflammatory and appetite-enhancing effects. My vets prescribed a herbal anti-inflammatory supplement, Nutramed, for Saoirse. It contains boswellia (used by humans with inflammatory bowel disease), milk thistle (for liver support), and maritime pine bark. Many kitties have pancreatitis as part of triaditis, where inflammation affects the intestines, liver, and pancreas. It might be worth discussing additional liver support with your vet (I gave Saoirse Hepatosyl). Here's another helpful link:
IBDKitties.net
I've linked to the page on the importance of vitamin B12 but the whole site is worth reading for any kitties with GI issues.
Finally, here's another extremely helpful link:
IDEXX Pancreatitis Treatment Guidelines
It's a great document - from a
very authoritative source - to use during vet consults when seeking to get the most suitable and helpful treatments for pancreatitis kitties.
Hope some of the above helps. Sorry it's so wordy but it's based on hard-won experience.
Cats can live for many years with well-managed chronic pancreatitis. Most of it can be done at home with prompt administration of the right treatments - plus the co-operation and support of a good vet!
I hope Maggie is feeling a bit better by now and that she'll be fully recovered very soon.
Mogs
ETA: Feline pancreatitis may occur secondary to toxoplasmosis, a parasitic infection. When performing a diagnostic work-up it may be advisable to ask the vet to also test for toxoplasma as a precaution (if only to rule it out), especially if pancreatitis is suspected in a younger cat or where there are clinical signs suggestive of a parasitic infection. (Note: There have also been
cases reported in the States where liver fluke caused feline pancreatitis.)
.
I will never forget the feeling of utter helplessness I experienced during Saoirse's first flare.
). Giving bupe as a precautionary measure can treat any 'occult' pain present. With effective pain management the cat is then less stressed and this can help reduce inflammation and resolve the flare faster.