Epogen or Aranesp? HELP before tomorrow's vet visit!!!!

[Leslie & Alley]

Hi everyone,
Alley's stopped using her back legs about 2 1/2wks ago. She has crf and is suffering from major anemia. The vet started her on Epogen which she was given for 2 weeks. I took her back to the vet to check her pcv and they were lower. AS IT TURNS OUT....the vet at the er did not tell me the Epogen had to go in the frig, so all the shots sat out on the counter. I didn't even find this out until on her return visit last Weds I was getting more Epogen and they brought it out in a baggie with ice. It was at that time I found out that all the Epogen I had given her for 2 weeks (7 shots) were no good!! I was sooo upset w/the weekend staff who told me it did not need to go in the frig. So, last Weds when this took place we tested her pcv and it had dropped to 14(lower) than before. Now this made sense, because non of her shots were any good except for the 1st one.

We started her on a new batch of Epogen last Weds and I am taking her back tomorrow to have her pcv checked again. However...now I have read that Aranesp is a better choice because the side effects are less. I have read that Aranesp takes longer to have any effect, but that Epogen can be very risky!! Should I change her to Aranesp?? Alley has had 5 doses of Epogen now that were not defective. I need to order her med tomorrow and I am worried as to....which one she should be on. Anyone have any experience with these???? I am hoping that if I should change...she has only had a few doses of Epogen and that it is possible to change her.

As far as her back legs....she has tried to use them a few times but the right leg seems to turn in a bit and also be a bit weaker than the left. We did get an
Xray of her spine and there was 1 area on her upper spine that looked a little thinner. They said the only way to know exactly what was going on...meaning (if it was a spine problem, bone cancer, infectious diease...possibly) was to do an MRI and that would cost $800.00 which I cannot do. They said it could be a blood clot but didn't think so...but also no way to be sure. They also said that because she is soooo anemic it could be from that. Since she has been home from the hospital about 2-3 wks....she is eating with the appetite stimulate and is bright eyed and bushy tailed. She can still sit up but not able to get her back legs underneath her completely...still. Although, she has tried a few times. Could this be from the Anemia????

In Short:
3 weeks ago... -6-11 Alley in hospital because back legs stopped working
- 6-11She was started on Epogen for 2 wks
-6-23 Back to the Vet to have pcv checked....found out the Epogen was supposed to be in frig, so 7 of the 8 shots were no good!!
-6-23 started her on new batch of Epogen everyother day.
--------------------Now I am wondering if she should be on Epogen or Aranesp!! But I need to know ASAP ...as I go back to Vet tomorrow and need to order more meds!!!!!
-

 

[OptOut]

No idea, but I'll be watching for answers. Boo is going to need Epogen soon (and I hadn't heard about Aranesp). Hope you get some good ones (and sorry about the refrigerator thing - bad vetty-bean!).

 

[Hillary & Maui (GA)]

Going to alert Jess & Earl to this post, she's a vet tech and may be able to help.

 

[Leslie & Alley]

Going to alert Jess & Earl to this post, she's a vet tech and may be able to help.

Thank you....Thank you!!

 

[Linda and Bear Man]

I have not used Epogen or Aranesp yet, but I will probably be starting soon with Bear Man. My vet looked into it a bit, and her suggestions was to go with Aranesp, as it appears there may be less risk of the antibody reaction. From my reading, it does take longer to kick in, so the kitty may have to be treated with a blood transfusion in the short term, until the Aranesp takes effect.

The following website has been very helpful to me with info on anemia, Epogen, and Aranesp.

http://www.felinecrf.org/anaemia.htm#aranesp

http://www.felinecrf.org/anaemia.htm#ep ... ex_procrit

Note that you should also consider giving iron supplements with erythropoeitin treatments.

 

[OptOut]

Linda, my vet said that kitties become resistant to the Epogen after a while. Does the same happen with aranesp?

 

[Linda and Bear Man]

Linda, my vet said that kitties become resistant to the Epogen after a while. Does the same happen with aranesp?

I haven't read anything about becoming resistant, just about antbody reactions developing. Do you think your vet was referring to that? My vet said she has read of cats being maintained on Darbepoeitin (Aranesp) for up to 1 to 1.5 years.

 

[OptOut]

I can't remember exactly what she said, except that the Epogen would stop working at some point and then the only thing left was transfusions.

 

[Jess & Earl]

Hi
Anecdotally, Aranesp (darbepoetin) seems to be less likely to cause reactions in cats than Epogen. You can switch to Aranesp without a "washout" period, if you'd like. Darbepoetin was not used as much as Epogen because of a major cost difference, but the prices seem to have evened out more recently.

 

[Linda and Bear Man]

I can't remember exactly what she said, except that the Epogen would stop working at some point and then the only thing left was transfusions.

I'm a newbie myself, but I think that refers to a time when the cat has an antibody reaction to the human erythropoeitin, and there is no other option but to go on transfusions. Transfusions can't be maintained for long either, from what I understand, because even with typing and cross matching, cats develop antibodies to the blood transfusions.

 

[Leslie & Alley]

Hi
Anecdotally, Aranesp (darbepoetin) seems to be less likely to cause reactions in cats than Epogen. You can switch to Aranesp without a "washout" period, if you'd like. Darbepoetin was not used as much as Epogen because of a major cost difference, but the prices seem to have evened out more recently.

Hi Jess,
Alley has had 4 shot of epogen 2000units/ml at 0.08 (160 epogen units or 8 units on u-100 syringe) this last week. She also had the 1 shot when they first started her on it about 3 weeks ago but then all the other 7 shots were no good because they were not out in the frige.
So, this is actually her 1st round on it..as of last Weds...since the other were no good.

Your saying I can switch to Aranesp now, if I want? I have read that it doesn't build anti-bodies like Epogen. Is it very common for cats to build anti-bodies to Epogen..or is it rare? I found that I can order Epogen through Walmart's Specialty Pharamcy for $30.00 a vial or 1ml.
Do you know where I can purchase Aranesp? I haven't found any place as of now.

 

[Leslie & Alley]

I have not used Epogen or Aranesp yet, but I will probably be starting soon with Bear Man. My vet looked into it a bit, and her suggestions was to go with Aranesp, as it appears there may be less risk of the antibody reaction. From my reading, it does take longer to kick in, so the kitty may have to be treated with a blood transfusion in the short term, until the Aranesp takes effect.

The following website has been very helpful to me with info on anemia, Epogen, and Aranesp.

http://www.felinecrf.org/anaemia.htm#aranesp

http://www.felinecrf.org/anaemia.htm#ep ... ex_procrit

Note that you should also consider giving iron supplements with erythropoeitin treatments.

Thank you sooo much!! That is what I have read as well. What are erythropoeitin treeatments? I am going to start her on pet-tinic..do you know if any pet stores carry it...all I have found is online.

 

[Linda and Bear Man]

This website lists two sources: http://www.felinecrf.org/anaemia.htm#aranesp

Quote from above link:

Aranesp

Aranesp is more expensive than Epogen - it comes in a 25mcg vial which costs around US$125-140 and which contains approximately four doses. However, since it does not need to be administered as frequently as Epogen, the cost should be the same overall. Unfortunately, most online retailers seem to sell a minimum of four vials, which costs over US$500. However, I have heard that CVS and Safeway may be prepared to sell one vial for around US$160 - 180.

RX USA sells four vials of Aranesp for US$509.08 or one vial for US$131.90 (you need the 25mcg strength). One person who used this company has apparently had problems obtaining a refund after the Aranesp was shipped incorrectly.

Drugstore sells four vials of 25mcg Aranesp for US$516.06 as at January 2008. I have used Drugstore myself for other items and have always received excellent service


Note that I live in Canada and can't use these sources. My vet located Aranesp at my local hospital pharmacy.

 

[Jess & Earl]

Hi
Yes you dont' have to wait.

The Aranesp can be gotten a human pharmacy or a hospital pharmacy. Cats can form anti-bodies to any of these products; anecdotally, they seem to be less likely to do so to darbepoetin than to Epogen. Aranesp is still more expensive, but not as much so (not hundreds of dollars more) as it used to be.

The anti-body issue is rare, but it is a real doozy. The cat starts to make antibodies to all erythropoetin, including its own, meaning that they become completely blood transfusion-dependent (which is not sustainable in the long term) . So as far as side effects go, it is extremely serious.

 

[Linda and Bear Man]

I have not used Epogen or Aranesp yet, but I will probably be starting soon with Bear Man. My vet looked into it a bit, and her suggestions was to go with Aranesp, as it appears there may be less risk of the antibody reaction. From my reading, it does take longer to kick in, so the kitty may have to be treated with a blood transfusion in the short term, until the Aranesp takes effect.
The following website has been very helpful to me with info on anemia, Epogen, and Aranesp.
http://www.felinecrf.org/anaemia.htm#aranesp
http://www.felinecrf.org/anaemia.htm#ep ... ex_procrit
Note that you should also consider giving iron supplements with erythropoeitin treatments.

Thank you sooo much!! That is what I have read as well. What are erythropoeitin treeatments? I am going to start her on pet-tinic..do you know if any pet stores carry it...all I have found is online.

Erythropoeitin is what you have been giving in the form of Epogen. Aranesp is another form of human erythropoeitin. Erythropoietin is the hormone made by healthy kidneys which stimulates the bone marrow to produce red blood cells.
I'm not familiar with the pet-tinic. My vet plans to give an iron dextrans injection with my first injection of aranesp.

 

[WCF and Meowzi]

Note that you should also consider giving iron supplements with erythropoeitin treatments.

I am curious to hear Jess' thoughts on this. The general consensus on the Yahoo CRF support group, if I understood their discussions correctly, seems to be to not supplement iron unless iron deficiency is suspected, with microcytosis anemia (eta: microcytic anemia?) as one indication. The concern with supplementing iron where it's not needed is, among others (I forget the other concerns, but they sounded reasonable), the belief that excess iron may cause oxidative stress. I think UC Davis was referred to in the discussions as one that's abandoned the practice of routine iron supplementation when there's no suspicion of iron deficiency.

Jess, what are your thoughts (and your colleagues' thoughts) on iron supplementation?

 

[Linda and Bear Man]

I think I remember Jess posting something along the lines of iron doing nothing but cause constipation (excuse me if I am mis-quoting you, Jess). I am interested in hearing if it something harmful that I should avoid doing.

 

[Jess & Earl]

I think I remember Jess posting something along the lines of iron doing nothing but cause constipation (excuse me if I am mis-quoting you, Jess). I am interested in hearing if it something harmful that I should avoid doing.

Hi Linda

I was referring to Pet-Tinic Oral iron supplementation is famous for causing constipation in cats. A lot of cats seem to take Pet-Tinic without an issue, but it does cause a problem for some.

WCF/Linda:

Way back when Earl started Epogen, the recommendation was to give iron every few weeks with the idea that we are 'forcing' the body to make red blood cells and want to be sure that we have all of the components needed to assemble them. Earl had severe, chronic intestinal disease and a previous history of malabsorption problems so this seemed (and still seems) reasonable. However, many cats with CKD (aka CRF) probably have plenty of iron they can use for RBC production and iron supplementation can become a burden to them. But you don't know which cat might benefit from iron and which cat has plenty, so what do you do?

There are two things. One is do a test for iron called a Total Iron Binding Capacity test. It's complicated, but basically this is the only test that checks for available-for-use iron within the body. Based on those results you would know who benefits from supplementation. The other option is to give a single iron dextran injection when starting Aranesp/Epogen, and dont' repeat it. This is considerably cheaper than doing the TIBC test. Personally I'd do the TIBC test since I can get a discount, if I couldn't than I'd just inject iron once and be done with it *unless* I had a cat like Earl who has had extensive absorption issues, or if I home-cooked for my cat or had any other reason to suspect that the cat might not have consumed or absorbed enough iron over an extended period of time. EDITED TO ADD: In that case I'd do the TIBC test to check.

I would not give oral iron supplementation since I think it is not well-absorbed and can cause GI effects.

 

[Linda and Bear Man]

Thank you, Jess.

With Bear's history of long term severe IBD, it sounds as though the iron dextran injection might be good for him.

Leslie, I hope Allie's visit went well today.

 

[Jess & Earl]

Linda, I realized my post was unclear so I edited it. I'd probably do the TIBC if I had to do things over with Earl because the iron level could be anywhere. If it is too expensive (I don't know how much it would be, you could ask your vet, make sure it's the TIBC and no other test), I'd start with one injection and then hold off for a while.

 

[Linda and Bear Man]

Linda, I realized my post was unclear so I edited it. I'd probably do the TIBC if I had to do things over with Earl because the iron level could be anywhere. If it is too expensive (I don't know how much it would be, you could ask your vet, make sure it's the TIBC and no other test), I'd start with one injection and then hold off for a while.

OK, thanks.

 

[WCF and Meowzi]

Thanks for your thoughts, Jess Looks like TIBC is the way to go then. Hopefully we'll never get to that stage.

Linda - it's past my bedtime, so I hope what I write is still coherent. A list-member of the Yahoo group did the tests last year after three different vets insisted that she supplement iron. Kitty's HCT was 22%; she did the iron tests at the suggestion of the fourth vet (there were three tests: Serum Iron, Ferritin, TIBC) at Kansas State for $138. (Hopefully it's cheaper if you just do the TIBC like Jess suggests, since that's the useful one). Kitty's ferritin was actually above the ref range, while the other two were right smack in the middle of the ref range. None of the values indicated iron deficiency or that kitty needed iron supplementation, despite being anemic for close to half a year. (She's not on epogen yet). The thread was an eye-opener because we see so many vets just put kitties on iron suppl because of low HCT.

Sorry for the thread hijack, Leslie. How did Allie's vet visit go?

 

[Leslie & Alley]

Hi Everyone,
Alley's visit went ok today. Since starting the new dose(good dose) of Epogen on the 23rd her PCV values were up 2 points from 14 to 16. Her kidney values have stayed about the same. They were lower but only by a few points (6-7). A few months ago I was told .....by the company I order some of her meds from (not the vet) to lower her subq's fluids because she had been in the hospital for low potassium. However at this time she was not on any supplement. The guy at the company said that they have 6,000 crf cats that they treat and that he would highly recomend lowering the subq's from 150ml 2x a day to 100 ml 2 a day because if she had more subq's they might not absorb and then that would cause her potassium to wash out. He said otherwise it would keep happening. So ...I did that and then on the 10th on this month is when she ended up back in the hospital for potassium and "also"dehydration again. Also at that time is when her Kidney values went back up.... to what they were before we started subq's. Since then, we have taken her back up to her normal dose of 150 ml 2x a day.

As of today.. her potassium has dropped down again but she is not dehydrated. We are increasing her potassium and going to re-check again next Weds.
So...today....her potassium is down..( but we are doubling dose)
her pvc is up 2 points from last week (a week on Epogen)
her Kidney have gone down a tiny bit (since giving her..her normal dose of subq's)but not where they were "before"I lower the subq's months ago

The Vet wants to keep her on Epogen, since we have started her on it and said that he just had one of this cats on Aranesp and that this cat started producing anti-bodies to it in the second week. He said that that we will check Alley and if she shows any signs of developing anti-bodies to Epogen then we will switch her to Aranesp. Althought, from what I have read....I am not sure that works. But I also read that Araesp that doesn't contain Albumin has a higher risk of anti-bodies....and I called all over today before I went to the vet and could not find anyone who carries Araesp with albumin.

The vet also wants her to take pet-tinic or Hi-vite drops. It is funny....because I asked him a million q's and the only one I didn't ask was about the iron shot!! Then, I get home and read your msg's regaurding the iron supplement.

I at least I researched everything before her appt today!! I am curious to see what you all think about her visit today and the test results. I might not have computer access myself tomorrow and most of Fri.....but I will have someone check msg's for me.

I am going to start her on Methylcobalamin and APF (which has mainly been used in horses and dogs) but now has also been used in cats. It is known to have helped greatly with muscle waste. It is cheap and offered at Thriving Pets.com now....so who knows maybe...if I can get Alley to take it..it might help.
I will call the company first to make sure it isn't going to be a problem with any of the other med's.

Thanks for all of your quick response's yesterday....it has been such a help and I know Alley probably wouldn't still be w/me if I didn't know what to ask and what to "ASK FOR"!! She is my heart and the days just won't be the same without her!!!! So, I am forever grateful to everyone on here who who gives sooo much of themselves!!
Let me know what you think of the vet visit today. xoxoxoxo

 

[Leslie & Alley]

Anyone have any feedback on Azodyl?? I am being told that it hasn't really been seen to do much by so vets.

 

[Larry and Kitties]

Some people in Yahoos CRF group use Azodyl and think it helps. However, there is some controversy whether it really helps the animal. Azodyl removes urea (maybe other stuff too) from the bloodstream and thus the Azodyl lowers blood urea levels which makes the CRF look not as bad. It is not clear if the loer blood level is really beneficial to the animal.

 

[WCF and Meowzi]

I'm back and my addled brain (didn't get enough sleep last night, darn!) has more questions

Jess, this is probably pertinent only to Bear, and hopefully not to Alley.

IIRC, Bear has recurrent pyelonephritis - I think he's on Baytril, either pulse therapy or continuously. (I personally think this would this is another reason Bear should be tested for iron deficiency before supplementing, IMHO). Anyway, my question is, how would iron sequestration in relation to recurring infection fit into this? And would supplementation even work if there's infection in the picture? (My project for tonight is to look up what happens to sequestered iron - where does it go? and if the TIBC takes it into account - I hope not. Leads are welcome :smile: )

 

[Linda and Bear Man]

I'm back and my addled brain (didn't get enough sleep last night, darn!) has more questions

Jess, this is probably pertinent only to Bear, and hopefully not to Alley.

IIRC, Bear has recurrent pyelonephritis - I think he's on Baytril, either pulse therapy or continuously. (I personally think this would this is another reason Bear should be tested for iron deficiency before supplementing, IMHO). Anyway, my question is, how would iron sequestration in relation to recurring infection fit into this? And would supplementation even work if there's infection in the picture? (My project for tonight is to look up what happens to sequestered iron - where does it go? and if the TIBC takes it into account - I hope not. Leads are welcome :smile: )

Apologies to you, Leslie for hijacking your thread! If you get a chance, perhaps you could remove the 911 icon from your first post.

WCF, you raise another good point. Bear is on Baytril continuously. It is always difficult to tell if he currently has an infection, if it's under control, or if it is gone (he never has a positive urine culture, even while very ill with pyelonephritis). I suspect it is always simmering, and would be back in full force if Baytril were to be stopped. There is always a large amount of blood and protein in his urine. I wonder if his Baytril is controlling his infection enough that he can use iron. If not, the Aranesp is not going to help him, is it?

ETA: I just checked the Idexx Canada handbook. The test is available, but is "referred out" (shipped on ice, results in one week), which means it is likely sent to MSU, and will be heinously expensive - probably in the $300 range like the other tests they send out like PTH. It is bundled with iron and UIBC tests.

 

[WCF and Meowzi]

WCF, you raise another good point. Bear is on Baytril continuously. It is always difficult to tell if he currently has an infection, if it's under control, or if it is gone (he never has a positive urine culture, even while very ill with pyelonephritis). I suspect it is always simmering, and would be back in full force if Baytril were to be stopped. There is always a large amount of blood and protein in his urine. I wonder if his Baytril is controlling his infection enough that he can use iron. If not, the Aranesp is not going to help him, is it?

I don't know, Linda. All I have are questions confused_cat - I'm not much help :sad:

There's also a couple of questions about ACE inhibitors and human erythropoietin - doesn't seem to include Aranesp - in humans, on Tanya's site. Did you see that? Bear's on benazepril, right?

ETA: I just checked the Idexx Canada handbook. The test is available, but is "referred out" (shipped on ice, results in one week), which means it is likely sent to MSU, and will be heinously expensive - probably in the $300 range like the other tests they send out like PTH. It is bundled with iron and UIBC tests.

Hmm. I would think iron tests aren't 'esoteric,' unlike parathyroid and acromegaly tests. The Yahoo listmate had it done at Kansas State Univ. May be worth calling Idexx to see if it's sent within Canada to some university lab?

 

[Linda and Bear Man]

I don't know, Linda. All I have are questions confused_cat - I'm not much help :sad:

There's also a couple of questions about ACE inhibitors and human erythropoietin - doesn't seem to include Aranesp - in humans, on Tanya's site. Did you see that? Bear's on benazepril, right?

You are a huge help, Choy-Foong. I did discuss the Benazepril with the vet. I even took Bear off it for a bit, then decided he needed the kidney support more, and that it was not likely the biggest contributor to his anemia. I was planning to revisit it with the vet before starting Aranesp. I also asked her about some of the things you asked me a while ago about his renal values not being all that bad, and that they don't really explain things like why his anemia is so severe. I asked if she thought his anemia was really of kidney origin. She wrote:

Anemia of chronic disease occurs via all the mechanisms that you described. It is frequently a slowly progressive, non responsive anemia that tends not to respond to epo injections as nicely as CRF associated anemias do. I don't exactly know what happened in September to cause his anemia to come to light. I think honestly, it is a multifactorial problem. If I recall, the ultrasound, although not specifically answering the cause of the anemia, did confirm that he has multiple chronic disease issues, including very unhealthy appearing kidneys all of which can contribute to anemias being present. I think I more firmly believe that his anemia is driven by his renal disease for two reasons. One is that despite the administration of b12 injections briefly improving the anemia, it has basically slowly progressed with time. The fact that he has never really had substantial increases in urea/creat do to some degree make CRF as the cause a little less likely, but I am also familiar with some cats who have CRF diagnosed with normal urea and creat..... For a long time we have known that his glomerular filtration is abnormal, its incredibly low threshold to glucose, the chronically low urine specific gravity, large amounts of protienuria..... I think sadly, that his kidneys are more unhealthy than his urea and creat levels want us to believe. I suppose I also want to hold out hope that if we tried epo he would respond well..... since CRF is the better candidate for this as you know.

 

[WCF and Meowzi]

Since starting the new dose(good dose) of Epogen on the 23rd her PCV values were up 2 points from 14 to 16.

Yay, it's going in the right direction

The Vet wants to keep her on Epogen, since we have started her on it and said that he just had one of this cats on Aranesp and that this cat started producing anti-bodies to it in the second week.

I'll preface this by saying I'm not a medical professional, veterinary or otherwise, so I could be entirely wrong here. But I wonder how the vet checks for an antibody reaction in just the second week? Tanya's site says Aranesp takes longer than Epogen to take effect, and that Epogen itself takes a couple of weeks to start taking effect. Also, the same site says there is no definitive test to show that the cat has developed an antibody reaction; "the main sign of an antibody reaction is that the cat's PCV value will steadily drop by approximately 2-3% a week, despite the use of adequate (emphasis mine) amounts of rhEpo (me: I assume it's the same for Aranesp). Large drops in PCV in the space of a few days or a week are very unlikely to be caused by the antibody reaction, and other possible causes such as gastro-intestinal bleeding should be investigated." So I'm guessing the vet is saying there's an antibody reaction because this kitty's PCV dropped? But what process does the vet use to attribute it to "antibody reaction" instead of Aranesp not taking effect yet, inadequate dosing, or other possible causes?

I'm not saying an antibody reaction isn't possible with Aranesp - there isn't any published literature on its use in felines yet, and it's only started to be used fairly recently. But I'm curious to know how he arrived at that conclusion, like maybe a new test has been developed?

Are you on the Yahoo CRF Support list? You may want to get some of the members' input on this; they've seen lots of cats on Epogen and, and recently, some cats on Aranesp.

He said that that we will check Alley and if she shows any signs of developing anti-bodies to Epogen then we will switch her to Aranesp. Althought, from what I have read....I am not sure that works.

Tanya's site writes that switching from Epogen to Aranesp after an antibody reaction worked for one kitty, but not others. I think it's the same kitty that she writes about later in the page, that was on immunosuppresive meds. Personally, I wonder about whether there's a higher risk of developing antibodies to Aranesp too; I'd think the kitty's immune system would now be on alert for "foreign" synthetic erythropoietin, and be primed to neutralise it? I don't know ...

But I also read that Araesp that doesn't contain Albumin has a higher risk of anti-bodies....and I called all over today before I went to the vet and could not find anyone who carries Araesp with albumin.

Try Drugstore - it's in Linda's post further up this thread.

I am going to start her on Methylcobalamin and APF (which has mainly been used in horses and dogs) but now has also been used in cats. It is known to have helped greatly with muscle waste. It is cheap and offered at Thriving Pets.com now....so who knows maybe...if I can get Alley to take it..it might help.
I will call the company first to make sure it isn't going to be a problem with any of the other med's.

Oooh do you mean APF drops? Be warned - they taste nasty :razz: I wouldn't put it in her regular food, you may turn her off it. Food aversion is no fun, esp with a diabetic kitty with CKD. The suggestion I got was to use an oral syringe, and draw in some clam juice too to mask the taste (I didn't taste it so I don't know if it did mask, but Meowzi did not approve).

I was advised to watch BGs while on it, that the numbers could drop - didn't happen.


PS - would you edit your first post to remove the '911'?

 

[WCF and Meowzi]

Anyone have any feedback on Azodyl?? I am being told that it hasn't really been seen to do much by so vets.

We use it. Can't say if it's doing anything, but don't see any harm in it, if it doesn't give Alley diarrhea. There's still an ongoing study, I believe it's sponsored by VIN. Remember it needs to be chilled, so don't just purchase it from any old source, if you're inclined to try it.

See http://felinecrf.org/treatments.htm#azodyl

Some people in Yahoos CRF group use Azodyl and think it helps. However, there is some controversy whether it really helps the animal. Azodyl removes urea (maybe other stuff too) from the bloodstream and thus the Azodyl lowers blood urea levels which makes the CRF look not as bad. It is not clear if the loer blood level is really beneficial to the animal.

Well, I don't think it claims to slow or halt the progresion of CKD. And it is possible that by using it to do a little bit of the kidneys' job, you may not get a realistic picture from bloodwork, of how much kidney function has deterioriated. But if uremic toxins makes a kitty feel bad, and reducing them makes her feel better, it's worth a try even if it doesn't do anything about the progression of CKD, yes? Quality of life is important; what really matters to me (and to kitty, I would presume to guess) is that kitty feels good.

 

[Jess & Earl]

ETA: I just checked the Idexx Canada handbook. The test is available, but is "referred out" (shipped on ice, results in one week), which means it is likely sent to MSU, and will be heinously expensive - probably in the $300 range like the other tests they send out like PTH. It is bundled with iron and UIBC tests.

Hi Linda

I didn't see it listed at the MSU lab. Kansas State does it, it is $22 US and you need to ship overnight with a cold pack. http://www.vet.ksu.edu/depts/dmp/servic ... edule.aspx If you can get your vet to draw the blood for you (you may have to pay a tech visit fee or some such) you can send it off yourself. I dont' know how you pay in US dollars, maybe a money order or something?

 

[Jess & Earl]

Hi Choy Foong

IIRC, Bear has recurrent pyelonephritis - I think he's on Baytril, either pulse therapy or continuously. (I personally think this would this is another reason Bear should be tested for iron deficiency before supplementing, IMHO). Anyway, my question is, how would iron sequestration in relation to recurring infection fit into this? And would supplementation even work if there's infection in the picture? (My project for tonight is to look up what happens to sequestered iron - where does it go? and if the TIBC takes it into account - I hope not. Leads are welcome :smile: )

I'm sorry, I have re-read this several times and I'm not sure what you're asking. I haven't slept more than 3 hrs at a time for more than a week now so I am quite fuzzy. Can you reword it or something? You're worried about Baytril causing interference with iron binding? Sorry.

 

[WCF and Meowzi]

Oh gosh, Jess. I'm sorry, I was thinking out loud when I wrote that, and it wasn't very clearly worded. It doesn't really have much to do with Baytril.

In short, all I'm wondering is if iron supplementation
1) will make an infection worse if there's an ongoing infection being suppressed by an antibiotic, or
2) will not work to alleviate anemia (if it's sequestered because of ongoing infection), or
3) will work work with erythropoietin to treat Bear's anemia in spite of the infection and antibiotic in the background.

The long version (and you may skip this) of arriving at those three questions above are (and I did a really clumsy job of it this morning!), if Bear's already on an antibiotic (any antibiotic, in this case it's Baytril) to keep his recurrent infections in check, would iron supplementation:
1) tip the balance in favour of the bacteria, if iron can increase bacteria growth? And what would be the consequences of this - would these turn into super-resistant bacteria if they've snuck through continuous antibiotic therapy.
or
2) would iron sequestration by the body prevent (1) from happening. does the iron just sit there bound and do nothing, then, even when erythropoietin comes along?
3) or, would sequestered iron unbind to make red blood cells when Epogen or Aranesp comes along, regardless of a possible infection in the background? Do pathogens take a backseat to the body's regular process; is there a priority of preference: which gets first dibs at the iron: bacteria, or epogen and bone marrow?

It is perfectly alright if you don't feel up to answering any of these; I know you're very very tired and hurting and distracted. These aren't pressing questions for now; I may actually get a better picture if I will just find the right stuff to read. I hope you'll get some rest, and get to spend time with Elliott. I can hound you with questions another time. (((Jess)))

 

[Jess & Earl]

Oh you always ask good but complicated questions

Honestly, the mechanics of iron storage, uptake, use, etc. are extremely complex. There seriously are PhDs who devote their lives to this one aspect of metabolism. So I can only speak in general and perhaps somewhat clumsy terms here ...

if Bear's already on an antibiotic (any antibiotic, in this case it's Baytril) to keep his recurrent infections in check, would iron supplementation:
1) tip the balance in favour of the bacteria, if iron can increase bacteria growth? And what would be the consequences of this - would these turn into super-resistant bacteria if they've snuck through continuous antibiotic therapy.

Iron is sequestered in the bone marrow when there is a chronic inflammatory disease due to cellular signals that accompany inflammation. Iron is also protected when there is a bacterial infection as bacteria need environmental (from the body) iron in order to grow. Iron is virtually never floating around loose; it is always bound up in one way or another. In cases of infection, the immune system tries to prevent iron from being taken by bacteria and bacteria evolve tricks to get the iron loose despite the hurdles thrown in front by the immune system.

I think you're wondering if the iron supplement will hit the bloodstream and be sucked up by the bacteria who will then go on a rampage of sorts? Remember that bacteria don't store or save up iron--they constantly need it, so even if they are washed-over with an iron supplement they can only take what they need at the moment and the rest will be bound up or excreted by the host's (cat's) body quite quickly. In terms of super-bug (you mean resistant?), I'm afraid the chronic Baytril use has probably already created those--nothing to do with iron.


or

2) would iron sequestration by the body prevent (1) from happening. does the iron just sit there bound and do nothing, then, even when erythropoietin comes along?

Are you still talking about infection or about sequestration with chronic disease? In cases of the latter, the epogen injection may indirectly stimulate some release of iron from the bone marrow where it has been stored. Generally speaking if you're trying to overcome the anemia of inflammation you may need to supplement despite good bone marrow stores because you have to get past the iron-retention mechanism.

3) or, would sequestered iron unbind to make red blood cells when Epogen or Aranesp comes along, regardless of a possible infection in the background? Do pathogens take a backseat to the body's regular process; is there a priority of preference: which gets first dibs at the iron: bacteria, or epogen and bone marrow?

So I think we answered part of this above. In terms of who gets what iron, I don't think there is a proper queue. Remember that iron is not only being sequestered but also carried in the blood and can be released for intra-body (is that a term?) use, so while bacteria have to fight for their iron scraps, bodily processes have more ready access.

I think I wouldn't hold tightly to the idea that iron supplementation is affecting an underlying bacterial infection because of what I said above, that bacteria can only make use of the momentary environmental presence of iron--they can't stash it. Also, though the mechanics are beyond what I know offhand, I do know that oral iron supplementation doesn't result in a massive overgrowth of intestinal bacteria so I'm inclined not to put too much stock it in. Furthermore, the bacteria should not be flowing freely all around the bloodstream but iron-binders are, so it stands to reason that they get first crack at any injected iron anyway.

This reminds me, you had another question that I kept forgetting to answer -- what was that again? Something about calcium?

 

[Linda and Bear Man]

So, what is the potential harm in giving Bear a shot of iron without doing the blood test first?

 

[WCF and Meowzi]

Oh you always ask good but complicated questions

I guess I have too much time on my hands now that we're syringe-feeding Meowzi instead of chasing her around at all hours begging her to eat

Iron is sequestered in the bone marrow when there is a chronic inflammatory disease due to cellular signals that accompany inflammation. Iron is also protected when there is a bacterial infection as bacteria need environmental (from the body) iron in order to grow. Iron is virtually never floating around loose; it is always bound up in one way or another. In cases of infection, the immune system tries to prevent iron from being taken by bacteria and bacteria evolve tricks to get the iron loose despite the hurdles thrown in front by the immune system.

LOL. OK my eyes glazed over. I had to read that four times. But I think I get it (And I hadn't known about anemia of inflammation )

I think you're wondering if the iron supplement will hit the bloodstream and be sucked up by the bacteria who will then go on a rampage of sorts? Remember that bacteria don't store or save up iron--they constantly need it, so even if they are washed-over with an iron supplement they can only take what they need at the moment and the rest will be bound up or excreted by the host's (cat's) body quite quickly. In terms of super-bug (you mean resistant?), I'm afraid the chronic Baytril use has probably already created those--nothing to do with iron.

Yes, I wondered if more iron = more fuel for the bacteria, and like little lizards on steroids they'd grow into Godzillas, go on rampage of sorts. Good to know they just take what they need at that moment.

Yes, did think chronic Baytril use (or any antibiotic for that matter) has already created super-bugs (yes, meant resistant). But was worried that with the additional iron, they become giant super-resistant super-bugs. What can I say, I have a simple mind So, while superbugs remain a real concern because of chronic Baytril use, iron-fortified supersized superbugs isn't a possibility, got it.

ETA: hmm. Excreted quickly? I was under the impression that iron isn't easily eliminated from the body (chelation therapy?), hence the caution about over-supplementing it. Am I wrong?

2) would iron sequestration by the body prevent (1) from happening. does the iron just sit there bound and do nothing, then, even when erythropoietin comes along?

Are you still talking about infection or about sequestration with chronic disease? In cases of the latter, the epogen injection may indirectly stimulate some release of iron from the bone marrow where it has been stored. Generally speaking if you're trying to overcome the anemia of inflammation you may need to supplement despite good bone marrow stores because you have to get past the iron-retention mechanism.

Not sequestration with chronic disease since I hadn't known about that. I was focusing only on the infection aspect. So you think iron injections may be helpful in this chronic disease situation then with Bear, just to get past the iron-retention mechanism, even if the TIBC shows he does not have iron-deficiency anemia? Trusting of course that Linda would clear this with Bear's vet or internist, before they start iron injections.

3) or, would sequestered iron unbind to make red blood cells when Epogen or Aranesp comes along, regardless of a possible infection in the background? Do pathogens take a backseat to the body's regular process; is there a priority of preference: which gets first dibs at the iron: bacteria, or epogen and bone marrow?

So I think we answered part of this above. In terms of who gets what iron, I don't think there is a proper queue. Remember that iron is not only being sequestered but also carried in the blood and can be released for intra-body (is that a term?) use, so while bacteria have to fight for their iron scraps, bodily processes have more ready access.

It does sort of sound like bodily processes may have some kind of first dibs then. Which would sort of make sense. Otherwise anyone who's fighting an infection or inflammation would encounter anemia (and worse), if the body just completely locks down iron, no?

... Furthermore, the bacteria should not be flowing freely all around the bloodstream but iron-binders are, so it stands to reason that they get first crack at any injected iron anyway.

"they" = iron-binders?

This reminds me, you had another question that I kept forgetting to answer -- what was that again? Something about calcium?

Steroids and hypercalcemia. LOL. That was months ago. I'll have to look up the PM and re-send.

 

[Jess & Earl]

So, what is the potential harm in giving Bear a shot of iron without doing the blood test first?

Hi Linda

Honestly, the iron "overdose" issue is more theoretical in cats at the moment, and while it makes sense biologically, I'd still do at least the first iron shot. The shots are every 3-4 weeks so you can always reassess later. This was the protocol for *years* (iron shots while giving erythropoetin) without OMG side effects, and given that we usually only turn to Epogen/Aranesp when we are at the end of the rope in terms of CKD-anemia, I don't see a huge contraindication for an iron shot. As I said, I'd do it again for Earl given his history of GI issues and CKD.

 

[Linda and Bear Man]

Thank you, Jess (and thanks so much to you and Choy-Foong for all your help with this). The vet advised me today that the cost of the TIBC test is $165 plus tax. I am leaning toward just getting the shot, despite reading I have been doing today about potential side effects of the iron shot such as allergic reactions and pain at the injection site. I am having such bad vibes about this whole process. Anyway, this is what the vet wrote me today:

From the reading on Aranesp that I was able to do today, it seems that the iron is administered pre-emptively at the first dose of Aranesp to ensure that iron does not get depleted and is available for formation of red blood cells. I read a few message boards on the subject, and unfortunately it's barely mentioned/explained. It seems that only one dose of iron is recommended, but one source did mention rechecking the TIBC periodically to ensure adequate iron levels. It certainly wouldn't hurt to measure the TIBC prior to starting Aranesp, but my understanding is that it is not necessary - the iron injection is strongly recommended for the first Aranesp injection regardless. Does this correlate with the information you've found at all?

 

[WCF and Meowzi]

He said that that we will check Alley and if she shows any signs of developing anti-bodies to Epogen then we will switch her to Aranesp. Althought, from what I have read....I am not sure that works.

Tanya's site writes that switching from Epogen to Aranesp after an antibody reaction worked for one kitty, but not others. I think it's the same kitty that she writes about later in the page, that was on immunosuppresive meds. Personally, I wonder about whether there's a higher risk of developing antibodies to Aranesp too; I'd think the kitty's immune system would now be on alert for "foreign" synthetic erythropoietin, and be primed to neutralise it? I don't know ...

More on this: Leslie, if you're a member of the Yahoo CRF Support group, see msg # 228329, for comments from Dr Julie Fischer of UC Davis re: her experience with aranesp as a rescue drug.

Linda, you and your vet may find that same msg useful too, if you're contemplating Aranesp. Unless your vet is already on VIN - Dr Fischer is a VIN consultant as well. Keep in mind that it was written in 2008 and may be dated; your vet can probably contact her (contact info in msg) to see if there's more current information. Link to the CRF Support group: http://pets.groups.yahoo.com/group/Feline-CRF-Support/

 

[Jess & Earl]

Thank you, Jess (and thanks so much to you and Choy-Foong for all your help with this). The vet advised me today that the cost of the TIBC test is $165 plus tax. I am leaning toward just getting the shot, despite reading I have been doing today about potential side effects of the iron shot such as allergic reactions and pain at the injection site.

Hi Linda

I think its reasonable to do the iron injection. FWIW, it hasn't been painful as far as I have seen. I have heard some vets say that but I haven't seen it. I gave Earl several iron injections; they have to be IM and he had very little muscle *and* he was not shy about giving momma a swat if he felt pain, but he took the injection well. I have administered them at work several times without getting grief from the cat about the injection.

I think allergic reaction is extremely rare.

 

[Jess & Earl]

ETA: hmm. Excreted quickly? I was under the impression that iron isn't easily eliminated from the body (chelation therapy?), hence the caution about over-supplementing it. Am I wrong?

Unwanted iron (that isn't snatched up and changed to a usable form) is pooped out, and iron is lost through skin and hair loss as well. The amounts excreted are minuscule, however, so if large amounts of iron are incoming, there is no way to get rid of the massive excess. Does that make sense? Small amounts of unwanted iron will pass out in the feces, but an iron overload requires chelation therapy as we don't have a good, efficient way of ridding ourselves of large amts of it.

Not sequestration with chronic disease since I hadn't known about that. I was focusing only on the infection aspect. So you think iron injections may be helpful in this chronic disease situation then with Bear, just to get past the iron-retention mechanism, even if the TIBC shows he does not have iron-deficiency anemia?

An iron panel (the TIBC is paired with one or two other tests) should reflect the amount of actively available iron.

It does sort of sound like bodily processes may have some kind of first dibs then. Which would sort of make sense. Otherwise anyone who's fighting an infection or inflammation would encounter anemia (and worse), if the body just completely locks down iron, no?

You need to be iron-deficient for a while to develop a secondary anemia from it so anything other than severe chronic disease shouldn't cause a problem. You are also constantly ingesting iron which can be used immediately upon absorption.

... Furthermore, the bacteria should not be flowing freely all around the bloodstream but iron-binders are, so it stands to reason that they get first crack at any injected iron anyway.

"they" = iron-binders?

Yes, iron-binders within the blood.

Steroids and hypercalcemia. LOL. That was months ago. I'll have to look up the PM and re-send.

About using steroids for treatment of hypercalcemia?

 

[WCF and Meowzi]

Unwanted iron (that isn't snatched up and changed to a usable form) is pooped out, and iron is lost through skin and hair loss as well. The amounts excreted are minuscule, however, so if large amounts of iron are incoming, there is no way to get rid of the massive excess. Does that make sense? Small amounts of unwanted iron will pass out in the feces, but an iron overload requires chelation therapy as we don't have a good, efficient way of ridding ourselves of large amts of it.

Yes, that makes sense, thank you.

Steroids and hypercalcemia. LOL. That was months ago. I'll have to look up the PM and re-send.

About using steroids for treatment of hypercalcemia?

No, it's a little more complicated than that :mrgreen: I can't find the PM; it's not in my Sent box anymore I hadn't known sent msgs are automatically deleted once I hit 200 msgs. From what I can gather from a later PM, it was a calcium/steroid/kidney stones question, I was probably asking about the wisdom or folly of putting her on pred if she's prone to hypercalcemia but is on calcitriol. There was a link to a write-up; I think it was on the MSU site, I'll have to look for it. We'll have to take this to PM-land or start a new thread (which do you prefer?); poor Leslie, I've hijacked her thread enough. I'll try to find the MSU link tomorrow.

 

[Leslie & Alley]

Unwanted iron (that isn't snatched up and changed to a usable form) is pooped out, and iron is lost through skin and hair loss as well. The amounts excreted are minuscule, however, so if large amounts of iron are incoming, there is no way to get rid of the massive excess. Does that make sense? Small amounts of unwanted iron will pass out in the feces, but an iron overload requires chelation therapy as we don't have a good, efficient way of ridding ourselves of large amts of it.

Yes, that makes sense, thank you.

Steroids and hypercalcemia. LOL. That was months ago. I'll have to look up the PM and re-send.

About using steroids for treatment of hypercalcemia?

No, it's a little more complicated than that :mrgreen: I can't find the PM; it's not in my Sent box anymore I hadn't known sent msgs are automatically deleted once I hit 200 msgs. From what I can gather from a later PM, it was a calcium/steroid/kidney stones question, I was probably asking about the wisdom or folly of putting her on pred if she's prone to hypercalcemia but is on calcitriol. There was a link to a write-up; I think it was on the MSU site, I'll have to look for it. We'll have to take this to PM-land or start a new thread (which do you prefer?); poor Leslie, I've hijacked her thread enough. I'll try to find the MSU link tomorrow.

No worries!! All this info is heplful to me as well!!