Fred: need advice on Pepcid dose, kidney CRF progression

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Martica and Fred

Martica and Fred

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Hi
As some of you may remember, I was giving my 19 3/4 year old Fred fluids since last June. Then Sept he started declining physically and getting rear leg collapsing when I gave fluids. In Jan he had a couple of hyperventilation breathing episodes and was diagnosed with CHF and HCM.

At first they put him on 4 heart drugs (2 bad for kidneys), and they drained the fluid from his chest. I stopped giving him fluids (two months ago). After 2nd day/3rd dose of all the drugs--he got really lethargic and not purring. So I took him off one of them (enalapril) because I was worried. He was on the other 3 for a couple more weeks. Then he started getting constipated and I took him off the Plavix. He was doing great, in general. Finally I went to get a 2nd opinion to a cat cardiologist (3 weeks after first diagnosed with the heart, and 2 weeks after the heart drugs).

He did a new echo and turns out fluid to the lungs had not returned and his heart was smaller. So good news, he was downgraded to 'mild' HCM with no cardiac heart failure (previously it had been 'moderate' with CHF--as a result of the fluids).

The cardiologist agreed we could try being conservative with the heart drugs because of the kidneys and his age. So he was taken off everything but Plavix, and also no fluids.

Six and half weeks later (yesterday) we went back for a check-up. Heart is good (still ‘mild’) and no fluids returning to chest. But his kidney values had worsened a little. (He has not had subQ fluids for a little over 2 months.)

He has lost weight—around ½ pound in past 6 months. I have noticed this. He is now 8.8 lbs (from his peak of 18 when he was a fat cat and younger). He is very skinny, can see his hip bones and some of his back spine.)

Here are his figures for last few months:

MONTH----------BUN-----Creat-----Phos-----Potassium
Dec 09 2009-----78-------4.2-------7.5-------4.1
Jan 18-----------68-------5.2-------8.2-------n/a
Jan 26-----------75-------5.9-------7.5-------5.0
Feb 04-----------86-------4.2-------n/a------4.5
March 23--------89--------4.8------9.2-------4.2

I was giving his EpiChitan (Phos binder) from Jan 26 to Feb 04, but then I think he started not liking it (that or the metamucil in his food). So since then I have cut way back on it. But his Phos has clearly gone up.

The cardiologist wanted to try him back on fluids again. So last night I tried giving him some. I gave him around 15-20ml (very hard to measure that small amount on the bag). He layed in the bed for another couple of hours with the heating pad on and it all seemed fine.

Then he started twitching a little—like trying to bite at his flank (itch? water under the skin?) Then I put him down and he legs were wobbly (like they had been after fluids back in the fall and early Jan). And he kept getting the twitching and a few times rolled backwards and fell on the floor trying to get at it. Then his back legs straightened and twitched a bit.

That lasted a few minutes and then he got a bit of food, wobbly, and peed. Then went to lie down. Then he wouldn’t purr, no matter how much I kissed/ petted him for the next few hours. Also would not react to me scratching under his neck (did not lift head). Clearly he was not feeling good. We went to bed and this morning he was good. Today, he has been purring and seems ok, perhaps a little weak. His breathing is fine, no apparent fluid in lungs.

However, this is now a dilemma. I don’t think the fluids are a possiblity again. For whatever reason he is having this reaction to them with the legs.

So his kidneys are liken to worsen...fast? He is losing weight pretty fast it seems.

In general--other than the weight loss--he has been GOOD--meowing tons, very affectionate purring, walking around, great blood sugar numbers. Loud meowing (has energy to do it.) But he is getting skinny/losing muscle, and is dehydrated.

But I need advice on what to do and how he will progress:

I have been watering down his Wellness and also squirting water into his mouth with a syringe (which he doesn’t mind). But I guess I can ramp up the amounts I squirt in from now on.

I will start being more regular with the epichitan.

He is on low carb/high pro because of the Dx (and blood sugar has been generally great). But should I got with the kidney food now? I don’t know if he’ll eat it, but will it really have an effect on the progression? His appetite is good although he’s def. eating less and in smaller amounts.

Also, wondering about the pepcid a/c (10mg tabs). He has been on a ¼ tablet twice a day. Should I bump that up? He is constipated pretty regularly (and throws up a lot of the time after he poops). Have been giving pumpkin and Miralax but not everyday since he sometimes won’t eat the food with that in it. I also have been cutting up barley grass for fiber in his food.

Most importantly, I’m wondering about the progression of the kidney disease. What should I expect? I do not want him to suffer and wonder how fast the decline is. I don’t feel good about the subQ. I”m waiting to hear about the cardiologist comments, I emailed him.

anyway advice appreciated.

thanks
Martica
 
Hi Martica,
I'm sorry Fred's numbers are worse and wish I had more info to help. Do you belong to any of the CRF yahoo groups? There are 2 that have a lot of good info: Feline-CRF-Support and Feline-CRF-Info.

I have always read that it's the high phosphorus that makes kitties lose their appetites and have nausea. Can you start the phosphorus binder again? My previous CRF kitty, Ginger (GA), was on Lactulose for the constipation and it helped. I would squirt it into her mouth with a syringe, so you wouldn't have to add it to food and it was tasteless. You might also try giving Fred some tuna water. Sometimes it will help them drink more water. One more thing, I think Fred's potassium is a little low. I add a fish flavored potassium powder to Blackie's food and he doesn't even notice it.

I can't advise on the progression of the CRF. ECID and some cats live a long time with high numbers. I hope Fred will eat better and that you can have a lot more quality time with him.
Ele & Blackie
 
Martica, wow - lots to balance there with him.

Do you warm the fluids before giving them subQ? Place the bag in a bowl of warm water for about 20 mins so they are about body temp. With so littel body fat, colod fluids might actually chill his blood and drop his body temp too low. Are you sure you are getting them sub-cutaneous and not into a muscle? (I'm just trying to cover all the bases).

Fluids with food are good - to a point. But they will dilute his electrolytes if you give too much.

Has he been tested for hyperthyroid? I would suggest the Free T4 by ED test as it is more sensitive. That could be why he is losing weight.

Why are you giving pepcid? Does he have pancreatitis? I usually only see pepcid give during a flare, not all the time.

Diet - maybe try half special diet food, low in phos and half low carb, high protein - and adjust the insulin as needed.

It's been too long since I have had a late stage CRF kitty, so I can't really say how fast things will progress at this point. My oldest is early CRF and she has maintained for over a year at the same stage. I did have a recent episode where she needed subQ for a few days and it turned out she has some mild pancreatitis. I thought she was making the move to subQ permenantly, but she didn't........
 
As far as I know, 1/4 tablet of Pepcid twice a day is the most you can give a cat...
at least that's the maximum my vet will allow Odie to have, and he's about 11 pounds.
 
Thanks, all good tips--

1. Hmmm...maybe I did get fluid in the muscle---I stuck the needle in lower than usual because I was thinking that might be less stressful to the heart--get it farther away from the heart and lungs. (My own un-evidence-based rationale.) However, I have a VERY short needle (I'm using a 26 gauge for the subQ and I think the needle is 1/2 inch, so in retrospect, I think it might have been hart to get it in muscle, but then again, I don't know. Still it was his legs that were twitch. But hmmm....I'm just afraid to try it again now)

I have tried warming the fluid bag in the past and just never had any luck. I would set it in hot water, I would put a heating bag on top of it for an hour and NOTHING seemed to warm it much. What I finally settle on was putting the heating pad (on top of a towel) on Fred while I was giving it to him. So he was cozy and it was not too bothersome that way. ALSO I use a VERY SMALL needle--26 gauge (compared to the 18 gauge the vets use). It goes in very slow and in very small amounts. I think it's likely that his body temperature will warm it as it goes in or not too long after since I'm not just dumping a huge load of cool water in him.

For anyone giving fluids I highly recommend using a 25 g or 26 g needle for the subQs. I kept trying smaller sizes and the 26g is great and the cat can't feel the needle going in. It's a little slower, but really not that much--and for the benefit of less water more slowly and no huge gouging of your cat, I think it's worth the extra few minutes.

2. Lactulose--I'm hoping I can just buy that at the pet store or does it need to be prescription. Sounds like a good alternative

3. Pepcid A/C is used for kidney cats because apparently they get nauseous (signs are swallowing, licking the lips, and of course throwing up--esp. after pooping--the strain induces it.) They are pretty much kept on chronic pepcid a/c for that reason. I'm just wondering if I should be bumping up the dose.

4. Didn't know the phosphorus made them feel bad, I'll go back to the binder.

5. Yes, he was tested for thyroid. It's fine.

6. I do belong to the CRF groups, but this board seems to have the most people and is also the easiest to navigate (the yahoo boards you end up getting lots of emails with the messages pasted over and over again, etc.) But I have posted there and am awaiting a reply. I just knew that there are some CRF savvy folks here, too.

thank you, any other comments welcome!
Martica and Fred
 
Pepcid AC (Famotidine) is in a group of drugs called histamine-2 blockers. Famotidine works by decreasing the amount of acid the stomach produces.

I am surprised that you recommend use of 25 or 26 ga needles for subQ fluids. A lot of people use 18 ga but many find those two large in diameter. Those people use 20 or maybe 21 ga ultra thin wall needles since the thinner wall results in a larger bore and faster fluid flow. A 26 ga needle would be slow unless you use a syringe vice gravity

Here is some data that shows that a 25 ga needle takes 13 minutes, a 26 ga 19 minutes and and a 20 ga 2 minutes. I do not know the volume but athe rslts are relative.

Flow tests.txt
MFG DIA LENGTH STYLE LOT 1 LOT 2 AVG
Terumo 18 GA "1""" T.W. 00:55 00:51 00:53
Terumo 19 GA "1""" T.W. 01:17 01:16 01:16
Terumo 20 GA "1""" U.T.W. 02:02 01:56 01:59
Terumo 21 GA "1""" U.T.W. 02:39 02:37 02:38
Terumo 21 GA "1""" T.W. 05:59 05:53 05:56 Sold Under
Sur-Vet Label
Terumo 22 GA "1""" U.T.W. 04:05 04:13 04:09
Terumo 23 GA "1""" U.T.W. 07:16 07:03 07:09
Terumo 25 GA "1""" U.T.W. 13:21 13:20 13:20
Monoject 18 GA "1""" N/A 01:15 01:18 01:17
Monoject 19 GA "1""" T.W. 01:11 01:09 01:10
Monoject 20 GA "1""" N/A 02:32 02:34 02:33
Monoject 22 GA "1""" N/A 06:21 06:08 06:15
B-D 18 GA "1""" N/A 01:14 01:10 01:12
B-D 20 GA "1""" N/A 02:28 02:29 02:29
Monoject 22 GA "1.5""" N/A 07:21 07:13 07:17
Monoject 22 GA ".75""" N/A 06:04 06:12 06:08
Terumo 27 GA ".5""" R.W. 33:10
Terumo 26 GA ".5""" N/A 19:17
 
odiesmom said:
As far as I know, 1/4 tablet of Pepcid twice a day is the most you can give a cat...
Click to expand...

that is correct. and b/c pepcid is excreted by the kidneys, you do want to be as conservative as possible with a renal kitty, since their ability to clear it is impaired, i.e. it could accumulate in their body.

couple of thoughts here. please keep in mind as you read, that i thankfully have no experience with heart issues, so i am approaching this from only our experience with CKD, and from what i've read:

- phos binder. i think you mean epakitin? it's a calcium-based binder and is not as effective as aluminium-based binders. don't know if you're familiar with scooter's site; there's a nice write-up on phosphorus binders there. with fred's phos level, i personally would switch to an aluminium-based binder, if his cardiologist does not oppose it. scooter's site has a nice list of sources for phos binders too.

- constipation. miralax is what we use too, but it is an osmotic laxative. with fred being so dehydrated (i'm guessing he is, by his bun levels), and unable to receive SQ fluids, i do wonder if miralax is the right laxative for him. you may want to ask his cardiologist for his thoughts. unfortunately aluminium hydroxide gel, the binder we use, has a constipating effect as well, which we try to counter with a larger dose of miralax.
 
hi martica, not much advice, but i am also giving noah (civvie) 1/4 pepcid BID for early CRF symptoms. it really helps, so i plan to give it as long as i can...

xoxo
sara
 
Thanks Larry, Yes, I know that the vets and many people use 18 gauge needles for subQs. But most people do not realize that they can do with MUCH MUCH smaller and the cat will love that! It might take 2 minutes to dump a load in with a big needle, but I'm not sure why it has to be such a hurry. With Fred, I would watch a TV show/news or something as I was giving it and have it be a cuddle session.

Yes, it went in slow but he didn't feel the needle go in and also he never had a lump of water and I think the water was probably warmed a bit as it went in because such a small amount and so slow. So for anyone NOT in a huge hurry, I would recommend it.

I was actually at somoe point going to offer folks that if they sent me a self-addressed stamped envelope, I could send a couple of 25 and 26 gauges that I have so they could test them out (without having to buy a whole box). I just went through size by size smaller and smaller till I found the best one for Fred. The 25 has a longer needle, the 26 is shorter--so you have to keep your hand on it so it doesn't slip out if the cat moves or stretches.

But Fred purred and slept the whole time I was putting the fluids in, testament I think to how nice the experience was for him. So for people who have cats that don't like it and/or struggle, the smaller needle and slower fluid is worth a try!
 
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