Convenia - "long-acting, single shot" antibiotic

I posted on this issue 11/9/09 on the old board and will probably post on it periodically since I see the abuse of this antibiotic more and more frequently.

Here is the link to that thread:

http://www.felinediabetes.com/phorum5/r ... 168,page=1

This is the first post:

Convenia....aka....."the two week antibiotic"....which is being used far too often without considering if its administration is appropriate or not. It is becoming the 'easy fix' for people who don't want to
give antibiotics to their cat twice daily.

(1/10/10 comment: Convenia does have its uses. For instance, for feral cats that will cannot be medicated any other way...BUT....you also have to weigh out the issue of a feral cat having an adverse reaction out in the wild....with no medical help available to him/her. Given this issue, you better makes sure that the rewards outweigh the risks. Also, for house cats that cannot be medicated any other way although I find that most cats will eat crushed clavamox in food or a whole pill in a Pill Pocket.)

One of my favorite consulting patients became extremely ill post Convenia administration. Can it be absolutely proven that Convenia caused the severe anemia in this patient? No - but the evidence is very compelling.

The good news is that we are on Day 17 and the patient is still alive. The bad news is that the vet bill is now $5,000 and we are not done yet.

When I did a search on VIN, I found a post that discussed severe hemolytic anemia in two cats. Both cats died - 1 within 7 days of Convenia, the other one on Day 10. Both had normal HCTs prior to the Convenia administration.

This drug is known to wreak havoc on the bone marrow and, according to one source on VIN, anemia was seen in the patients post convenia in trials that were done outside of the US but no anemia in the patients involved in the US trials.

Please keep in mind that when you inject such a LONG ACTING drug into a body.....if that drug exerts a toxic effect on the body, you are in deep trouble because you can't retrieve the drug.

When a drug has a long half-life, you better be sure that it is a safe drug to be giving and that you have a very compelling reason to give it.

Please note that this patient was given Convenia for an off-label reason - ie - a dental. This is not an appropriate use for Convenia since there are much better choices for oral bacteria. Convenia is labled for skin infections.

Plus, this patient just had a *routine* dental - no extractions - no significant gingivitis. The patient did not even need antibiotics which makes this case even more heartbreaking.

It is interesting to read posts on the VIN dental boards that have the specialists speaking out about the abuse of antibiotics in dental patients. They frequently comment about the overuse of ABs in this area.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Patient: 9 year old neutered male. Healthy...goes in for pre-dental blood panel and CBC on 10/21/09. All is well - HCT = 41%.

Timeline:

1) healthy - normal full blood panel and CBC the day before a routine dental (Day 1 = dental day 10/22/09)

2) no gingivitis, no extractions - ie - no reason for post-dental antibiotics

3) my client picks up her cat and is asked to give clavamox…..why?....we don't know since there was no indication that abs were needed

4) client says patient is hard to orally medicate so they give a shot of Convenia

5) note that Convenia is NOT labeled for use for dental issues - it is labeled for skin issues - the spectrum of this drug is not targeted toward oral bacteria

Day 3 - 48 hours post dental/convenia - listless, ate half of normal amount

Day 4 -72 hours post dental/convenia – ate a little bit then vomited it up….later that day, vomited blood-tinged fluid

Day 5 - 96 hours post – HCT (the measure of the percentage of red blood cells in the serum) had gone from 41% pre-dental to 31%

client called me for a consultation on Day 7 and I did a search on VIN and found a post from last Feb that outlined the cases of 2 cats – separate practices – that had died within 10 days post Convenia – with severe anemia

Day 8 - patient was taken to a 24 hours critical care facility where his HCT was measured at 33%.

Day 9 – HCT down to 26%

Day 10 – HCT at 28%

Day 11 – IN HOUSE test showed 34% - most likely an error

Day 12 – HCT down to 22%

Day 13 – HCT down to 20%

Day 14 – HCTs were 18, 21, 24, 22 – Bone marrow results showed Panhyperplasia with relative erythroid hypoplasia meaning that RBCs were not being produced normally.

The patient was discharged on Day 14.

Day 16 - He is eating well but is a bit weak and tired. Today is HCT is 27%.

Day 17 (11/7/09) - HCT = 25%

For the past 25 years as a practicing veterinarian, I don't think that I have ever stuck a needle into a patient or given them a pill without stopping and thinking about it. Does the patient really need this drug? Is it the right drug for the situation? The correct dosage? etc..etc....

It has been frustrating to watch Convenia being reached for - in many instances - because it is *convenient*....NOT because it is actually the right thing to do for the patient. The drug does have its legitimate uses but I also see quite a bit of abuse involving this drug.

This patient did not even need antibiotics and, even if he did, Convenia was not appropriate for use with oral issues. Now the client has a bill that is over $5,000 and is hoping that her cat lives and has not had his life shortened.

 

I ran across this vet's blog one day and saw this article:

http://www.mypetsdoctor.com/convenia-an ... -injection

Out of curiosity I searched convenia on the whole site. The vet is sure enthused over it, yet look at the laundry list of comments on the article above.

My questions are....while it is currently specified for skin infections, wouldn't it still play havoc with the bone marrow? Are there other safer ABs for those too? It seems like if it is a dangerous AB, it should not be in use even for that.

 

My cat Mal, recently diagnosed with FD, had gone to the vet on 9/29/09 because she had scratched herself raw on her neck. She received a Depo-Medrol injection and a Convenia injection. When I asked what he was giving her, the vet told me an antibiotic shot that lasted for two weeks in the cat's system. He didn't ask me if I wanted to give oral antibiotics, he simply gave her the shot. It wasn't about an easy alternative for me, it was about what the vet chose to give the cat.

I have been using the same vet for over 13 years. Like most people, I trust my vet to know what he is doing. However, when Mal was diagnosed with FD, I started researching the disease and the treatment options. My vet wants to treat Mal with Glipizide for her diabetes and I don't. Mal will be seeing a new vet tomorrow.

Taking the initiative to find out more about FD led me to finding information about proper nutrition for my cats and my dogs. I'm learning more and more as I go and this forum has been a big part of my education, but not everyone takes the initiative to learn more. As I said, I believe most people simply trust their vets to know what's best. As pet owners we should be responsible and know more about pet nutrition and medical treatment and hopefully more can be done to change the mindset of people when it comes to these issues.

 

so what do we do instead? my cat's on something like 9 meds now and she's a Bi*** to pill. it's the only thing she's fought me on and she's stubborn. she is going to need something.

she was on azithromycin but it gave her terrible diarrhea and vomiting that even cerenia can't stop. clav makes her vomit too. not sure if clindamycin will be as bad for her as the azithromycin was. she possibly has an infection from a tooth issue but we're trying to balance a lot of stuff at the same time. getting the tooth looked at today and tests run. she's congested to boot, and not responding to l-lysine this time. her BGs are higher right now, too, which makes me suspect infection even more.

onco vet is still pushing convenia on me. she won't give me ondansetron for nausea; cleo is on cerenia for vomiting, mirtz for inappetance and depression (it's the only thing she's on that has some antinausea properties and she's still clearly nauseated), and on CCNU and pred for lymphoma, and injectable B12 and B complex and denamarin for liver issues..

don't know how many choices i have. she mentioned anzamet today when i said no to convenia. cleo was on convenia once before after her spleen was removed and she had no adverse effects.

i'm actually calm when i'm writing all this but jeez when we have so much going on i'm not sure what kind of antibiotic would be best if she does end up needing one. she does have some anemia (not bad level of it) so it makes me even less interested in convenia but she's feeling so awful i have to do something for her besides fluids and giving her baby food every half hour.

 

Oh I'm sorry Chris, I didn't know she was feeling so poorly.

Cerenia is an anti-nausea agent but apparently isn't working for your girl. Dolasetron (Anzemet) is another great anti-nausea drug, if she's willing to try that I would go for it. You can see if it can be given SQ. I think so, but I don't remember. (We administer it IV in the hospital but some drugs can go SQ as well.)

Our oncologist is about the only one in our hospital that uses Convenia, I think partly because she uses that family of antibiotic in general, and partly because her patients and clients tend to be pill-weary.

The anemia that stems from Convenia is a idiosyncratic reaction -- the *exception*, rather than the rule -- and I don't think it should be counted out of the antibiotic arsenal. This family of antibiotic (cephalosporin), among a few others, has been linked to anemia in dogs (immune-mediated hemolytic anemia, if anyone wants to google) but I used a member of this family for a dog of mine with a wicked secondary skin infection. It was the best antibiotic and it was a chance in a million she'd have that weird reaction. (Note that we don't know the exact chances with this drug in cats, it's too new.) From Dr. Lisa's posts on the old board, she doesn't think the baby should be thrown out with the bath water either. I think she's decrying the uninformed use of it (i.e. the administration of it to uninformed clients) and the over-frequent use of it. For a cat who is intolerant of x, y, and z antibiotic and for whose infection a cephalosporin antibiotic would be useful, it is a choice worth discussing IMO.

Remember Chris that some antibiotics, including clindamycin, can be injected rather than pilled. If you are giving fluids that can make it even easier. Someone on the board said their cat was very sensitive to clindamycin injections (acted like it stung) but I've given it w/o incident, and one of my coworkers had a cat on clinda for 3-4 weeks BID injections without incident, so it might be worth a thought.

Off the subject of Convenia and back to Cleo, I'm just so sorry she's feeling crappy. Where is she in her chemo? Have you discussed changing regimens? IIRC she has small cell lymphoma, right?

 

Yep. Well said.

I just want people to be informed and if they have a choice of another, safer, LESS LONG-ACTING antibiotic - with an appropriate spectrum - then please choose something other than Convenia.

 

Are there any other types of infections besides skin infections that this *is* appropriate to try *if* you have a hard time pilling? It sounds like it could be, even though skin infections are what it is approved for and apparently most efficacious in. It could help for people to know that.

 

I get what you are asking but I need to clarify for other people:

I am not a fan of pilling any cats - in general.

Unless the patient is clearly better about pills versus liquids, I always favor compounded flavored liquids.

IF pilling is done, all pills need to be 'chased' with food or 4-5 cc of liquid.

Now - to answer your question: A urinary tract infection that has had a C and S run....that shows susceptibility to this drug class, would be an example.

It should be kept in mind that this drug stays in the body for 2+ months and that the potential for bacterial resistance may be higher than with other - short-acting ABs - given the gradual decrease in serum levels of this drug.

 

PS...I will continually remind people that clavamox works very well for most cats when crushed and mixed with canned food. I have treated many feral cats this way.

 

i posted a reply a while ago that seems to have been eaten. lol.

just wondering, now the vet wants to inject cleo with Baytril if some stuff she suspects comes back with the urine/blood test results. (she suspects URI because of cleo's high temperature and colored urine.) cleo has FORLs but is not considered a good candidate for a dental at this time (the vet is a board-certified dental specialist), and the area of her gum where the tooth broke off does not look infected to the dentist. originally between that and some bad congestion we had considered giving her convenia but i balked so she got anzemet instead (sp).

i'm just as scared of baytril as i am of a few other drugs. should i not be? honestly, i don't want to be a pain to this vet but it's more important that i keep my kitty safe. if we have to choose between baytril and convenia, which would be considered safer/more effective?

 

Morris was treated at my vet yesterday for impacted anal glands. My vet wanted to give him a shot of Convenia afterward because there was white matter in the stuff that came out of the anal glands (sorry, don't know the medical terminology). I declined the shot for now but, since Morris is impossible to pill, he is not getting any a/b. He is also not eating well right now so putting it in his food is iffy. He's scheduled for a dental next Monday so she can recheck the anals then and see if there is any infection.

He had 2 shots of Convenia to clear up a UTI back in August, with no ill effects...this was before I read about Convenia here. Two questions:
1. Is the anal gland issue considered one of the indications for Convenia use??
2. If he had it twice already with no ill effects, does that mean he will most likely be OK to get it again???

 

A while ago I asked about the injectable Baytril for my civi's UTI (he was previously on Clavamox) but it came back) in order to start the antibiotic treatment). She said thee was no one on VIN (veterinary Information Network) that supports the use of injectable Baytril for cats.

 

thanks for the clarification, larry.
now, wouldn't you know the vet said she'd be giving injectable baytril. (that rang a very scary bell in my head.) i asked about blindness and she said i have to understand that no antibiotic doesn't have detractors or potential negatives so there's no "perfect" one.

i mentioned issues with convenia on VIN and she told me not to pay attention to VIN coz people are often wrong there.


as you quoted me, better correct that i meant "board certified veterinary dental specialist as well as internal medicine specialist"

so i guess i'll be asking about anzemet again as the AB...

 

Wow...that's a great attitude to have. I guess that all of us who post regarding serious adverse effects may as well just not waste our time and....the practitioner who posted regarding the two cats that died post Convenia should not have bothered to post.

The problem is when doctors DON'T post on boards like VIN. The suffering continues because everyone like your vet is just sitting in their own, lonely corner of the world and not keeping up on possible issues with drugs.

There is no doubt that there are pros and cons to all drugs. That goes without saying. However, it goes back to be informed.

Chris - what about using Zenequin? Clarification - I make that comment without having read this entire thread. I only say that because there may be less of a chance of blindness with Z over Baytril.

Also, I think if I remember correctly from what I read a few days ago, you were getting Convenia mixed up with Cerenia?? It seems like in one sentence you talked about Convenia in the same sentence as an anti-nausea drug.

Sorry...I am really busy lately and am having a hard time keeping up with reading and responding to posts here.

 

right, dr lisa.
the first (and only) time cleo got convenia i was happy coz i thought i'd heard good things about it on this board. turns out i had mixed it up with cerenia. as she's on cerenia now, no more mixup for me.

preliminary blood/urine results back with no sign of infection so far so looks like it's a moot point. C&S results will probably be in another day, tho.

yeah, the vin comment irked me. tho i do understand that a semieducated client (feline health wise) can be annoying, so she might have been reacting to me. they only scheduled her for 15 min with me so she was rushed and having to handle more stuff with cleo than she had time for. (she was getting u/s, blood & urine tests, plus crisis mode coz she wasn't eating and she was acting pretty sick with 103 temperature, plus dental checkup, and they only scheduled her for the dental checkup.)

 

Yes, they can be more time-consuming but I would MUCH rather deal with an educated client. MOST of the time they can be LESS time-consuming to deal with...and a lot more fun because I feel like the pet is getting better care.

 

Actually, IIRC, the pharmacology guru on VIN uses Baytril SQ in cats. I know a lot of vets use it but some vets are aghast at the mere thought of using it -- it's one of those type of issues. It can cause skin irritation (pretty bad in some cases) so most people use it very low dose (so low volume) or dilute it.

As I mentioned in my previous post, anzemet is an anti-nausea drug (and a very good one). It's not an antibiotic.

 

Pearl has a permanent bald spot on her scruff from it

 

If you are talking about Dr. M, no disrespect to him intended, and I am not even sure how to word this but.....I sometimes notice a lack of a 'practical/real world' outlook in some of Dr. M's suggestions. A bit too much 'book learning', if you will....too much strict pharmacology and not enough worry about side effects, in my opinion.

That said, Baytril is another situation of not throwing the baby out with the bathwater. I used it in my Robbie...who I love more than anything....a few years ago for a nasty liver infection. However, if I had to pick a fluoroquinolone today, I would probably pick Zenequin.

 

Aw, Dr. M, yes. I have to say, as someone whose dog has chronic hepatitis, he will always hold a place in my heart for not saying that azathioprine is the only answer and for giving clear, precise alternative protocols for treatment of a disease that no one wants to touch (because all the DACVIMs find it hopeless and unrewarding). Also for writing out protocols for non-NSAID treatment of OA (again because my creaky 13 year old can't have NSAIDS because of the dang hepatitis!). That said, I get the book-learning vs. real world difference (though I do think he is in practice still) but in this case I have seen him object to its IV use and certain doses due to concerns over retinal nerve damage in cats--he also says he has used it SQ, and so have a lot of others. I researched injectable ABs at some point a few years ago for my late cat who had issues with oral drugs (due to nausea). I don't remember what he says about dilution ratio, however.

PS. I ended up seeing if my cat could rid himself of the snotty URI, and he did despite his leukopenia. Go figure!

 

What you wrote about Dr. M....shows that we all have something to offer and the differences between us all just add to the spice of life.

I used it SQ in my dearly departed, Buck, about ~6 or 7 years ago. I can't remember if I diluted it with normal saline or sterile water but I think I diluted it 50:50....or 1 part Baytril to 2 parts NS or SW?? Can't remember.....but I think I remember that Buck lost his hair in that area. But hey....his chin abscess sure cleared up and he did not end up bumping into walls so, overall, a success!

 

Still on the subject of Bayril....I just find it very annoying when B is used in cases where clavamox would be just as (or more) effective - and safer.

(The cats who puke up clav not withstanding.....)

 

I strongly suspect that my cat died last week as a result of a Convenia injection for a UTI. I will go into some detail here as I just got the records. I would appreciate feedback from Lisa as to whether IMHAnemia was the cause, and her opinion as to how the course of events was handled. IMHA seems clear to me and I'm unhappy- ok, heartbroken - with some things that were done or not done.

On 3/23 I brought 15 yr old Maya in as she was losing weight, still eating wet, but no munching on dry and refused her favorite treats. She had vomited up liquid a few times. Had a full senior blood workup done and urine taken. Gave her fluids. Had lost 3+ pounds since 1/10 visit. The vet gave her a shot a famotidine(Pepcid) - told me after it was done, which didn't sit well with me, but I'd come to trust this vet. Later learned it's not recommended for older pets or those with liver issues. She told me to give it to her orally as well, as it works so well to settle the stomach.

Blood tests revealed hyperthyroidism (T4-5.5). I think liver enzymes were elevated, have to check what all these acronyms mean. Also a urinary infection - notes say "marked bacteria 740/hp (?). (Notes are quite difficult to read.) She prescribed methimazole for the thyroid and said a shot was a choice for antibiotics for the UTI. Sounded good to me, Maya wouldn't have to down too many pills. (Yes, I mixed them with food). So she got a shot of Convenia the next day, along with the prescription and some Hills A/D cans. She developed a recurrence of respiratory infection (had at 2 yrs old), probably due to the stress of the blood and urine draws. Appetite bad during the 4 days it took to clear that, but was decent some days after that.

4/9 Blood recheck. She'd lost another pound of weight. Meanwhile, I'd decided to do the radioiodine therapy as the cure rate is so high for hyperthyroid, provided the blood test was ok. It wasn't. WBC had shot up from 11.2 previously to 40.8 - I've since read that this "leukemoid reaction" is one indicator of IMHA. I'll include HCT progression, as Lisa seemed to go by that in a previous post. HCT went from 37.3 previously to 34.1. ( I have all numbers, please ask if it's important). RBC from 7.88 to 6.79. Vet advised a 2 week course of Zennequin to clear whatever infection she must be fighting, and to discontinue methimazole. (I've since read that methimazole has also been known to trigger hemolytic anemia.) Got fluids.

4/22 Another blood recheck. Lost another pound, now just under 7 lbs. Appetite continues to deteriorate. Now showing signs of jaundice (another sign of IMHA). WBC had come down to 28. HCT down to 29.9, RBC still 6.79. Vet described fatty acid lipidosis, and told me how many syringes of food I needed to get into her every day. Still recommended Pepcid. I was not told about a feeding tube, which I now know is the best option. I did my best with the force-feeding, but it was hell on both of us and I know I didn't always get enough in.

4/24 Vet calls to see how she's doing, to bring her in for more fluids if she's not doing well, would like to do another blood check at the 1-week mark.

4/26 I go in and ask to be shown how to do fluids at home. No problem, so I start doing this every day. I can't believe how skinny she is and am starting to wonder how long I'll put her through all of this with continuing decline and no sign of improvement.

4/29 Blood recheck, fecal, she's gained 2 oz! Vitamin B12 injection, which I'd asked about to stimulate appetite. Maya is now getting very wobbly, unsteady and has other symptoms of ataxia. I mention the wobbly symptom, which is fairly new. Vet tech says she is very yellow, try to get her as much food as you can. By now she's eating very little on her own, still taking tuna juice, one of her favorite things ever.

4/30 Blood results - WBC back up to 47.7. HCT down to 23 (I see in the notes "regenerative" - don't remember ever hearing anything from her about anemia.). RBC down to 4.54. She says that blood pathologist suspects a neoplastic condition. Lab test notes do say this, also noted absolute reticulocyte evidence of regenerative anemia - 127,120. She offers to refer me to a oncology specialist, which I decline. Suggests trying prednisolone and leukaran. So I start her on the pred, but after checking on leukaran I don't think she could tolerate it.

5/3 She's gained another 3 oz! By now, she's only taking water on her own. I take her in because her anal area is inflamed the night before, worried about anal glands - at this point, I was actually hoping for an infection to explain the WBC. Nope, nothing is wrong, but Maya gets to have a finger up her butt, more stress and discomfort. I ask a lot of questions about her condition and this vet, who I've seen before, is very forthcoming - they see "yellow" cats probably only 2nd to UTI frequency she says, and they often don't make it. She suspects liver cancer in Maya. Says best bet is Prednisolone and fluids. She decides to show me her method of force-feeding, so a tech comes in and does a great job of demonstrating, but I think Maya gets a little too much food. She vomits a bit when we get home, a rare occurrence throughout this whole event. Overnight, she lets go of a lot of fecal material and had diarrhea a lot of the next day. I give her mostly homemade chicken broth. Her hind legs have become nearly useless. Very weak. The following day I wake up and she has that "vacant" look. After many tears, I decide to make the call. A while later, she takes some tuna juice. Then a little whipped cream, her most favorite treat of all time that she's refused for a month. Hope is rekindled and I'm unsure what to do. By night, my housemate says, "you have to end this. She's not just sick, she's dying." The next morning, as the car is running to take her in, she goes on her own.
I ask them to do a basic necropsy, as I'm sure they'll find something. The vet calls a short time later - there is some fluid in the abdomen, could have been FIP she says. Liver was slightly enlarged - she mentions fatty acid lipidosis again. No cancer evident, but it could have been in the bone marrow she says. No cancer evident.

I am haunted by all the stress I put her through force-feeding, etc., but mostly by the feeling that I failed her. I didn't even know how much I loved her.

So, my question is - was there negligence here? Is the diagnosis too unclear to cast blame anywhere? Would prednisolone have been a better choice than Zenequin when the WBC shot up initially, even if the cause was unclear?

Any comments are welcome, and thanks for a place to let all of this out - I hope I didn't go on too much.

Cathy
for Maya

 

Hi Cathy

I am so sorry to hear about Maya. You have my sympathy.

Dr. Lisa probably can't comment on a specific case on a public forum for legal reasons. To reach her privately, you can go to her website catinfo.org to see about arranging a consult. She does nutritional consults so this is likely out of her usual range, but that is the best way to make contact with her to see.

I am a trained critical-care veterinary technician, now specializing in cardiology. I can give you a few thoughts as I read through your record. I'll comment on a few things and then be more specific. Let me first stress that I am giving you my own thoughts, and know nothing about this case specifically, and can't give more than conjecture here, ok? Ok ...

I can tell you first that this does not sound like Convenia-related hemolytic anemia. If I am reading correctly, your kitty declined about a month after the injection. In the cases I know of wherein there was a severe reaction, the cats developed severe anemia within a week and usually were gone in 10 days (to be blunt).

I don't know where you read this? But it's not true. Pepcid is standard for upset stomachs and vomiting in cats, inc. old cats. The caution for use with liver patients refers to patients with severe liver dysfunction only. I agree, though, that doctors should always discuss treatment with clients beforehand.

Do you have the exact numbers? It is not uncommon for hyperthyroid cats to have some mild liver enzyme elevations.

Cats with hyperthyroidism are also more prone to UTIs, unfortunately. Did she get the urine from the bladder, with a needle? How did she get the urine sample?

One thing we do recommend around here is that urine be sent out for a culture, to make sure we are using the right antibiotic. Bacteria can be resistant to different antibiotics.

Do you have the urinalysis results? Was there any bilirubin in the urine?

Do you have the WBC differential? It should give a breakdown by type of WBC (neutrophil, etc). This could be going up because the UTI is not being treated--the bacteria *could* be resistant to Convenia.

That's not a leukemoid reaction per se -- all you have here is increased WBC, and I'm not sure what type.

These are within normal limits, still, and there isn't much difference between those numbers. If I tested my cat's HCT today and again on Wednesday, I might get either of those numbers, either day, and that'd be fine. (I'm not saying your cat was fine at this point, I'm just giving perspective on these numbers.)

Methimazole, although a life-saving drug, can be a very tough drug and cause a lot of issues, it's true.

Jaundice is also a sign of liver disease. Was a blood chemistry done now? What were the liver values?

The HCT drop from 34 to 30 wouldn't cause jaundice, so I think you're looking at the liver as the culprit here. (Jaundice in HA is from breaking open the red blood cells.)

Yes--food is the medicine for the liver in these cases. A feeding tube would have been the way to go--I'm so sorry that wasn't part of the discussion

She could be weak, or it could be encephalopathy from the liver. You dont' have any liver bloodwork results from this time?

Her decline is very sad. From the pieces of the story you've told, it could be liver failure (causes all these things, including fluid in the abdomen) or cancer. Cancer is always a suspect in a rapidly declining older cat. They didn't send out any biopsies for the necropsy? That would have given answers.

I can't say--I dont' think anyone reading this can say, one way or the other--because we're only hearing part of the story here. I would say that you need to speak to your vet. Leave a message for the vet saying you're feeling really bad about Maya's last days and need to go over things with her. Write your questions down beforehand. Ask the vet what she think happened, then ask your questions, and be specific. The vet deserves the chance to address your concerns about her and the possibility that she could have done a better job. Listen first, then ask.

I can at least say no to this question. There was no evidence of hemolytic anemia at the time, and prednisolone can encourage infections (rather than fight them) so giving pred to an animal who is known to be fighting infection is a no-no in almost every circumstance.

I'm sorry, Cathy, for all that you've been through. As far as the force-feedings and such, I think that you need to remind yourself that, had things turned around for Maya, you wouldnt' give a second thought to all the treatments you did for her. It's only when we help them fight and we end up losing them that we second-guess ourselves. We still have to fight, if there's a reasonable chance that we'll get them back to health. We can't see the future.

Please take care, and feel free to post again here, or on our grief forum, if you need to reach out.

edited for clarity about pred vs infections

 

Jess & Earl - thank you so much for your reply. My mind is eased a bit, but I'd like to answer your questions to try to provide a clearer picture. As far as talking to the vet again? She/they were quite honest along the way as to being stumped about what was going on, so I don't think there's any more they can tell me. Very caring people - I don't suspect bad intentions at all, but it is a busy practice and good intentions don't always equal good doctoring. So, some answers and comments: (Excuse me if the quotes are messed up)

No biopsies - of course, I wish I"d asked for that now.

Thank you for your kind words and your expertise. We lost a 17 yr old cat last year, and for some silly reason I thought it would be easier this time! Nope, but there are others here to love on and that's the best therapy of all. I've also gained a whole lot of knowledge that will hopefully benefit them.

Cathy

 

Do you have the exact numbers? It is not uncommon for hyperthyroid cats to have some mild liver enzyme elevations.

Elevated ALKP 507(0-62), ALT 295(28-100), AST 133(5-55). Mild? After 2 week methimazole, came down to ALKP 329, ALT 115 - still high.

I've just been reading about the liver and these numbers look horrible.

From vetinfo.com:
Alkaline phosphatase (ALP) is found in many tissues but in cats the
majority of this enzyme in the bloodstream comes from the liver. This
enzyme is excreted in response to bile duct obstruction, making it pretty
specific for this problem in cats. It can take awhile for production of the
enzyme to start and it will be produced as long as the condition persists,
so levels tend to start out low and then rise over the course of an illness
in which bile flow is obstructed. Large rises in the ALP level tend to
indicate pretty severe obstruction to bile flow which has been present for
some time.

I'm back to being crazed about what was not done.

Cathy

 

Hi Cathy

I'm happy to help if I can, and will try to respond tomorrow. to be honest I left work after 9pm tonight and am eating and answering email and taking care of (my own) animals at the moment; let me get back to you ok? I'm writing now so you know I'm 'listening'

 

That is so sweet of you - of course, whenever you have time.

 

Hi Cathy

Ok I checked into a few things. So I do have to wonder about there being a liver issue from the getgo, as there was bilirubin in the urine. Bilirubin in the urine (bilirubinuria) is a sign of liver issues in cats. Dogs sometimes have a small amount in their urine but cats shouldn't. Now the liver values in the blood were high, but not jaw-dropping. I've seen values in the thousands in cats with hepatic lipidosis. I do wish that repeat chemistries had been done as she was worsening as this might have shed some light on things.

The CBC results do look abnormal to me, not what I'd think typical for a cat fighting a UTI. I'll show it to some colleagues and see if anything looks striking about it (besides it being fishy), I'll let you know if I have any revelations..

So I still think there's good reason to suspect primary liver problems and possibly cancer, given her age. IT sounds like more certainly could have been done in terms of diagnostics and treatments, but with an elderly cat with multiple issues, things may have been uphill. Liver disease alone is a real SOB to treat, in part because there just isn't a lot to do about it--it's all supportive care to try to allow the liver time to heal on its own. (My own dog has chronic liver disease so I am familiar with all the options and non-options :roll: )

One thing that you can do in the future, if it's an option given your location, is get a second opinion. Word of mouth is a good way, or you can also look for a feline-only vet or a vet that put in the extra effort to get certified in general-practice training http://www.abvp.com/ . If it's something complicated, you can also see an internal medicine specialist. Before I worked in this field, I had a cat with chronic intestinal disease and both our lives would have been a lot different if I'd gotten him to an internist sooner. I didn't know at that time what a difference an expert could make.

Take care, Cathy, and as I said feel free to post again here or even on Grief.
Jess

 

Jess, thanks so much for that info, it's definately another clue. The color was orange too - NOT EVEN NOTED in the clinic notes. I also find it interesting that the Urinalysis was missing from the original file, along with a few parts of blood tests. I had one of the desk girls print it up for me another way. This seems like an awfully basic thing to miss. I almost have to wonder if she just thought a 15 year old cat probably wouldn't make it anyway, so why drag it out.

From what I've read, there are several liver conditions that can play with the WBC - neutrophilic cholangitis/cholangiohepatisis (there really seems to be a problem with standard naming of conditions Platelets were clumped from the very start - not sure what that means. Poor clotting?

I'm sure it would have been an uphill battle, but I would have wanted the opportunity to fight it with her. No question that if I had known what I know now, I'd have gone to an internal medicine specialist.

I'm going to attempt a phone call with the vet who saw Maya only once and last ( who seems very sharp) to ask her some questions about all this. Then I'm going to write something up and probably send it to everyone who had anything to do with the case, the head of the hospital, maybe VCA headquarters - I want to do my best to see that the next cat like Maya is treated better - and if that vet is incompetent, she should retire. (not old at all though) I can't tell you how many times she said "Thank you for everything you're doing for this cat." Just kills me.

Maybe the title of these posts should be changed in case anyone else runs across something similar here? I just got here, so I'll leave that up to you.

I can't thank you enough for your help Jess. I've gotten a few things elsewhere, but you've most definately helped to complete the picture.

Cathy
for

 

Hi Cathy

Oh what a cute face! I love the winky-sunny-sleepy look too.

I am always quite reluctant to assume malice when there may just be ignorance, to be honest. The bilirubin was within normal limits for a dog, so what if it was just passed over, or thought of as not significant in light of the whole clinical picture? That's what I can't give you, BTW -- an assessment of the 'big picture' since I'm not a DVM who has personally examined/dealt with your kitty. Let me also say (regarding the bilirubinuria specifically) that it is more of 'red flag' -- something that makes you look closer, rather than an 'OMG this cat's liver is toast!'

You mention the urine was orange. Was it very very concentrated? (Urine specific gravity can tell you this.) That might be able to give a false bilirubin result.

Ha, yes, anything to do with bile gets slapped with the "cholang-" mouthful. Cat platelets are very clumpy, that is normal. At the lab, they will prepare a slide of the cat's blood to make sure there are enough platelets as the machine can't count the clumps very well. That's why you'll see a "platelet estimate" listed as well.

Oh I agree you should have had that opportunity. I really regret not getting my late cat to an internist sooner. I think that vets deal with -- much more than we realize-- people who won't do XYZ test, or treatment, or spend XYZ, or put hours of daily work into their animal's care, and may sometimes fail to see those of us who would gladly do almost anything. If anyone of the 4 or 5 vets I saw with my cat had said, you know, you could see an internist, his case is rather unusual -- I'd have done it. I was making very little $$ at the time but would have gone. No one had answers--that's ok, he was a weird case and they can't know everything -- but also no one told me where else to look.

Is that the head of the hospital? I would call him or her, ask them to review the case, and call you back. If this last vet is not related to the hospital, or isn't the director, I would call and ask for an appointment to talk to them and offer to pay for their time. I'd be careful *not* to be accusatory -- you dont' want them to think that you're out for blood, and want them to say something incriminating about the other vet -- but rather that you are feeling bad about all this (which is true) and are looking for answers (also true). But definitely talk to the medical director of the hospital you dealt with the most. You'll be getting another DVM's opinion and starting the in-house review process of the first vet's work.

Let me also say that you want to bend over backwards to be polite and calm. People who come across as belligerent, hysterical, or otherwise wild/nutty have their opinions more quickly dismissed. Write your questions down, including potential follow ups, before you speak to anyone, and don't accuse but rather ask for an explanation. For ex: "In a case such as Fluffer's, wouldn't it have been reasonable to do XYZ follow up test after receiving the results of the blood chemistry?" rather than "Why didn't they run XYZ test after they found out that Fluffer had ZYX?"

Just my $0.02. YOu can keep us posted, you can start a new thread in the Community section. (I don't think these msgs can be separated from this thread, so they are stuck here.)
Jess

 

Yeah, she was a cutie. A real pistol though! Part Siamese, she once charged an American Staffordshire dog (pit bull lookalike) that was walking outside the patio. The look on his face (and his owner's) was priceless.

No, I don't want to assume malice, but it was a thought. Can you tell me what "taking a closer look" re the bilirubin would entail, as a standard? Certain tests?

Specific gravity was in normal range - 1.037

Yes, I'm sure vets deal with that a lot - the costs of some treatments/tests does make one pause. But this vet knew that I was ready to do the radioiodine treatment for the hypothyroid condition - $1300 - and that's not even a necessity. The last vet who saw her threw out "well you could try an ultrasound but that's $500." It sounded like a crap-shoot, so my jaw dropped and I said nothing. Had it been suggested to me earlier, along with the need for a liver aspiration (AND a feeding tube), I would've given it some thought and then done it.

Great advice, and yes, I'm prepared with questions and to be as calm as possible. So, is an in-house review kind of a standard thing that I can ask for? The vet I was going to call is not the director - I don't know if there is a director, but there's an "owner" who started the practice 40 years ago. Never met him, but he signed the sympathy card that was sent.

I always wonder how these practices are run - are there meetings where different cases are discussed? Is there a standard protocol for how different conditions should be treated, ideally?

One more question - I don't see a recording of temperature taken anywhere in the file - wouldn't that be a normal part of a full exam?

Yes, maybe I'll do an update in Community when all is said and done.

Thanks again Jess,
Cathy

 

Hi Cathy

Oh I just meant immediately investigating the possibility of liver disease, so further testing.

No, it's not an official name, but it is standard for complaints about medical treatment to be raised with the medical director who then reviews the chart and contacts the client. You can just call the front desk and ask who the medical director is, in case the owner is not.

This probably varies greatly from practice to practice. Large practices often have "rounds" where they discuss their ongoing cases on which they can use input. Individual vets have the option to treat as they see fit; the only standard protocols would be things that might be important to the medical director such as "we never use XYZ drug in cats" "we discourage declawing", etc.

Yes, for sick animals, with exceptions. For example, for cardiology appts we never do temps on cats w/o clear indication (we think they may have an infectious disease) because we need them to lay down quietly and be slathered in ultrasound gel for their echo -- our pre-echo physical has to avoid riling them up. If a cardio patient is doing poorly, then they get temp'd as patients in cardiac crises can become cold.

I'd be surprised if there was never any temps done, unless your cat was so fractious she could barely be handled. Even then, with the raising WBC count, they must have done one. It could be written in an unfamiliar way such as
BT:100F or T:100 or something like that.

 

Jess -

Have you ever heard of a superinfection response with Convenia? I read at Merck that that's a possibility with Cephalosporins.

[/quote]
I'd be surprised if there was never any temps done, unless your cat was so fractious she could barely be handled. Even then, with the raising WBC count, they must have done one. It could be written in an unfamiliar way such as
BT:100F or T:100 or something like that.[/quote]

Only 1 temp (101) recorded on the first visit - before the high WBC.

Anyway, the review is in process - I spoke to the medical director today and she was very gracious. Wants to go over it with a doctor coming back next week. I sent her a detailed list of my concerns and hopefully I wasn't too dramatic. I don't think she's a vet, but...

Also, I spoke to the secondary vet (last one to see her at the same clinic), which started out ok but ended with me in tears and her frustrated. She went to Princeton/Tufts, talks a mile a minute - I got comments like, "there's not much you can do for the liver", "I would have done the same thing", when I brought up things that could have been done or weren't done I got "mm, hmm'. She actually said at one point that I could have done more - as if I don't already feel that way. BUT, since then we've been emailing back and forth, she's sending a good amount of info and feedback.

Cancer is unknowable at this point, but everything points to bile duct obstruction from my lay-person crash course viewpoint. Bilirubin in the blood was at normal levels on the first 2 tests, so she wasn't yet near jaundice condition - agree, Jess?

Thanks again for listening and helping. Your input has been invaluable. I know there may never be a clear-cut resolution, but I feel good that they're taking a look and taking it seriously.

Cathy

 

Hi Cathy

I'm so glad that you're getting some answers, or at least the opportunity to be heard, and it sounds like your cat's case may impact future handling of such cases at the clinic.

Cephalosporins, like other antibiotics, can have a host of rare, weird side effects. This is a "zebra" in your kitty's case, however. [You know the expression: If you hear hoofbeats, think horses, not zebras.]

Yes, her jaundice would coincide with rising bilirubin. As to the bile duct obstruction, there are blood results that would show that, and ultrasound results, but since no further blood chemistries were done we'll never know. In the necropsy, though, I would think the vet would have noted a gallstone or other obstruction in the bile duct.
Take care
Jess

 

Are you talking about bile acid response? She thinks that's a waste of time. The ALP and GGT were both elevated on the 1st test - from everything I've read, those are both related to biliary obstruction. She did agree that the liver enzymes were too elevated to be a hyperthyroid effect.
She also said that Actigall has fallen into some disfavor - have you heard that?

 

Hi Cathy

The bile acids test is a test of liver function; it's usually not the first test done in adult animals because if you have a suspicion something is wrong with the liver already, you need to figure that out and treat it. For my dog, for example, I did serial blood tests, ultrasounds, and a liver biopsy to diagnose him. I know he has chronic cholangiohepatitis now, and every 10-12 months I do a bile acids test to check liver function. It's a "waste of time" in that there is nothing we can do about his liver function, really. But I do this in case he needs (heaven forbid) an emergency procedure or medication, so we know if he has enough liver function to tolerate XYZ. It is also a means for me to monitor (unfortunately) the decline of his liver, since I'm not about to do liver biopsies all the time and his liver enzymes are chronically elevated anyway.

You didn't mention the GGT previously. That is indeed a sign of biliary tract disease, not necessarily obstruction. I think you are saying obstruction when you mean disease? an obstruction is an emergency condition in which bile is completely prevented from flowing. ALP is elevated in different types of liver disease, but yes it can also be elevated in biliary disease. My dog has confirmed cholangiohepatitis and has mild GGT elevation, moderate ALT elevation, but normal ALP.

Nope, no idea what she's referring to. It is prescribed for liver patients all the time. My dog's been on it for two years. It's important to note that Actigall cannot be used in cases of biliary obstruction, but is absolutely standard for biliary diseases like cholangiohepatitis and cholangitis. A lot of feline vets use it for triaditis, a chronic condition, since it may have some mild anti-inflammatory effect.

 

Hi Jess -

How old is your dog? How lucky he is to have you caring for him so well. I had lab mixes many moons ago - they were great. I'd love to get a little guy one of these days, but the cats are priority now.

Good memory! Yeah, I probably didn't know the significance before.

Yes, I mean dysfunction of some kind.

Well, that's interesting. What do you think of Denamarin? I like holistic treatments whenever possible, but they're probably better in the early stages or as a preventative. We still have 5 cats here, so anything I'm learning may come in handy. Besides knowing what a sloppy job was done this time. Sloppy is the best word I can come up with :>) - I was looking through the file again and saw that her ALT was elevated on last year's blood test, and Triglycerides. Didn't hear about it. Same doctor and I remember the phone call - she told me about BUN slight elevation, not the other two.

The medical director left a message to call her today - haven't called back yet. I just don't even know what to say anymore. I'm so frustrated and - demoralized, I guess - by the whole thing. I wish I'd never set foot in that place.

As always Jess - great info, so appreciated.
Cathy

 

Hi Cathy

How did the talk with the hospital manager go?

He's 13.5 yrs. So far it looks like his liver will last him his lifetime, as it is progressing slowly and he's old already for a large-breed dog.

Denamarin actually is a liver treatment in allopathic vet med too; there isn't much that can be done (prescription drug-wise) to support the liver so SAMe and milk thistle are standard. SAMe is all-around a good support drug for many things, including osteoarthritis. The trouble is, Denosyl/Denamarin works best when swallowed whole so it's difficult to use in cats.

How elevated? I'd bring this up with the medical director too, if you didn't already. Triglycerides can bump up for benign reasons and unless it was very high, it's not too remarkable. Even slight elevations in ALT can occur sometimes, but if the elevation is more than "barely elevated", it's a good idea even in asymptomatic animals to recheck the ALT in 2-3 months, to make sure the elevation doesn't persist. My dog's diagnostics started like this, with a senior wellness check up that showed elevated ALT, then serial bloods showed persistent ALT (and then GGT) elevation so I knew something was up.

 

Hi Jess -

Good to know about SAMe - now I can use the box I got for Maya with my 14-yr old, who I know has a bad hip.

The ALT was 103. But the BUN was barely elevated at 38, so why tell me about one and not the other? I brought this up through email with both the vet and the medical director - that they might have suggested that I have it rechecked in 3 months or so. TRIG was 143.

I also brought up how yet another vet there missed a 20% weight loss(over 6 months) in January, when I brought her in for an overgrown imbedded claw and an ear infection. I thought the weight loss was a good thing at the time, as she was on the heavy side. If you're going to charge a $55 exam fee, then take 5 minutes to look at the big picture, eh? (I didn't say it that way though, haven't mentioned $$ once.)

Haven't spoken again yet to the director, but I'm sure they're sick of my emails, so probably will Mon or Tues. It's just harder for me to maintain composure on the phone, and I am at a weak point with all of this, so I'm not really looking forward to it.

Cathy

 

I see there are variations by lab in normal ranges. By some, ALT of 103 wouldn't be considered elevated. By some labs, the AST of 48 would be considered elevated, but that didn't flag as high on this report. Uugh.

 

Hi again Jess -

I spoke with the medical director today. She offered to send the case for review anywhere I'd like. Now please, don't feel obligated in any way, but I have to ask - is there a DVM where you are who would do a 2nd opinion/evalution and some kind of writeup on it? I thought it might be of help that you're familiar with the case. I'd be glad to pay. Are you in Georgia or New York? I'm in Florida.

And if it's no, for ANY reason - no problem whatsoever.

The medical director is very sweet and understanding - she actually had me laughing. She said they all feel very bad over there, but I don't know that that means they feel they could've done better.

Cathy

 

Hi Cathy

So the medical director offered to forward the records (which you already have?) and let you pay for a consultation elsewhere ... How generous :roll: At least it seems like you've generated a lot of discussion over there, which might be the best you can hope for.

As for consultants, why not contact Dr. Lisa? Her email addy is somewhere in this thread, or her signature or something. She may be able to refer you to another consultant, if she herself isn't available.

 

I have another thread going on right now, in the general cat forum, but I'm hoping for some clear answers before tomorrow morning. Have to take our civvie cat in for a rodent ulcer, that definitely looks infected at this point. She had three of them last year, and received two convenia injections, one was with a vetalog injection, the second was with a depo medrol injection. The third one was just a depo medrol injection I think because it was not infected that time.

I honest to goodness don't know what to do. Twix is NOT a cat you can pill, so it has to be given through injection. She needs an antibiotic and a steroid to take care of the rodent ulcer, but now with this thread going on I'm scared to do another convenia injection (I didn't even know she got this twice before until I pulled out her receipts) I'm also nervous about the depo shot because IF twix was to become diabetic, I know we could never treat her for it. She is not the type of cat you handle.

I feel like I'm going to be sick over making the right choice on what to do and now time is running out ... her appt is at 9 a.m. tomorrow and I'm at a total loss .... if anyone has any ideas on what we should do, I would be more then grateful to hear them ....

 

Crush clavamox tablets - mix into canned food

People often forget that clavamox tablets fed in a Pill Pocket or crushed up in canned food or baby food works wonders.

I have yet to have a cat refuse to eat crushed clavamox tablets in canned food. This is how we treat ferals that need to be on ABs.

 

twix is 6 years old and has never once kept a pill down. Only one vet was able to even get it down into her, and she foamed the entire pill back up within seconds. I bet she would eat the clavamox in wet cat food, but she only developed the rodent ulcers after eating the wet cat food. Got back on dry for almost the past year and developed another one, we assume from eating some of mochas wet cat food.

if her rodent ulcer is infected, does she need the antibiotic, or would the depo medrol shot take care of the infection as well??

I haven't gotten much information in regards to my question on what I should tell the vet I want, and I'm starting to get panicky over making the wrong choice.

 

You are really jumping to conclusions that canned food caused a rodent ulcer. It is about ingredients, *not* form. Going back to dry food is not the answer and, as you well know, can cause a myriad of other problems - most notably urinary tract issues.

 

I probably am jumping to conclusions about the wet cat food, but I can only go on what we have seen, dry food all her life with no problems, switched her to wet cat food and within weeks got a rodent ulcer, changed to a different wet food, got another one, changed again, got another one, got back on dry, no ulcers for 8 months, saw mochas wet cat food bowl had been left out, a few days later an ulcer shows up.

I know dry food is not the answer, but right now I'm just more concerned on what I should ask the vet for. Clavamox seems to be a decent antibiotic, but again, she can't be pilled and I'm nervous about giving her wet cat food. She also isn't a cat that we can pick up and syringe it into her mouth unfortunately.

 

if we were to try baby food with twix and clavamox, what is the best kind to buy her, I mean flavor wise? I honestly believe twix has allergies to beef and fish in wet cat food. But I have no idea on what flavor baby food to buy her

 

ABOUT THE BABY FOOD:
When Fluffy was so sick recently he would eat the chicken and gravy baby food. He really
liked that flavor. But Fluffy is not diabetic.

I am so sorry about those ulcers. That must be very trying for you!

 

Peter & Devon,
What you call "rodent ulcers" can be caused by an allergic reaction. SO, there is something in the wet food she is allergic to and that ingredient is not in the dry food or not in the same form so does not affect her the same way. Please see this wiki article:
http://en.wikipedia.org/wiki/Eosinophilic_granuloma

Gandalf was treated with Depo Medrol for this condition over 7 years, but didn't develop diabetes until about 3 years after his last Depo shot. The condition stopped after I moved from the apartment we lived in for those 7 years. And he was also fed Science Diet dry hairball Control food for almost that long too. So you're right to be concerned about the Depo, but in light of what Dr. Lisa has seen with Convenia, it seems the lesser of 2 evils.

 

We are discussing apples and oranges.

One is an antibioitic and one is a steroid. This is not an 'either/or' situation.

 

Bumping up Dr. Lisa's post.

 

discussion went off a lot on tangents but just wanted to add that i wish vets would tell their clients before injecting their cats with "unknown/unnamed" substances, and let them know potential side effects and what to watch out for so they can give informed consent.

when cleo got convenia, the vet did what others have mentioned and took her into a back room and injected her without even telling me. at the time we were concerned about skin infection so i do think it was a good use of the drug and cleo had no adverse reactions. but i hear more and more stories of vets taking action without first informing the client. in a case of a drug with serious side effects that increased tendency gets a lot more scary. i don't know how we can fight this battle except for one vet at a time.

 

Bumping up Dr. Lisa's post again.

 

Hi Pamela,

Thanks so much for bumping this up. I am getting so tired of seeing this antibiotic over-used and abused. It is making me a bit crazy....and very frustrated.

 

Dr Lisa, I'm not sure if you'll have the time to answer this, but I have a question about what is considered a "skin infection" (which you said Convenia's supposed to be used for). Back in February one of my cats had a very large abscess, probably from a bite or scratch from one of our other cats. She had to have surgery for it, and had a drain put in (she had two drain tubes, actually). At the time I didn't know much about Convenia, and that was the AB that was used (Sasha also had a dental with an extraction done while she was under for the drain). Would the abscess have been an appropriate use of the drug, or am I just lucky that Sasha didn't have any problems with it?

Thanks for any info you can provide.

 

Would it have been absolutely impossible to treat her with a much safer drug like amoxicillin? If the answer is "no", then it was inappropriate to treat with a drug that stays in the body for over 2 months.

 

Thank you for the quick reply! I will consider myself lucky that she didn't appear to have any problems from it. I have a hard time giving ABs (when I've had clavamox they kept spitting it out, and wouldn't touch food with it mixed in), but I'd rather continue trying something else rather than give them something inappropriate.