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Panic said:
That's what I was thinking, so they can have their official week. I was thinking about going to corporate directly again because the hospital can always be "too busy" to take calls and a corporate call can't be ignored. I just don't want to come off as pushy but ... I expect an answer.
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If you were not planning on using these vets again, I would do what ever would make me happy, but if you plan on going back I would be considerate of what they think.
 
Not that I personally know of...I might check that though in case such a deadline exists. I think mainly I just want the overdose to be admitted and that they are going to take action that it doesn't happen again. If they're fine dosing that high with other cats then it needs to go to a state board.

And I am absolutely not going back, I could never get the taste of what happened out of my mouth.
 
I asked a vet forum about whether I should contact the clinic again or a contact the state board and every one of them said that 100mg was a common amount they give to cats and that it is not an overdose??

I can't find an official chart from the drug manufacturer to back up the correct dosage but they've all reflected that the dose would have had nothing to do with it and doesn't cause respiratory failure. What they're saying doesn't even match what everyone here, my personal vet, or articles online say.
 
I'm not sure?? I'm honestly so upset I had to delete my thread because the comments kept coming that I was wrong to think it was an overdose. To think they're all out there giving that dose on a daily basis to cats. Even my friend who's a nurse and her husband who worked in a vet clinic both agreed gabapentin causes respiratory failure and the dose was too high. I won't even know how to argue this if the Banfield vet says the same thing.
 
Yeah, I think they are temporizing, using the ambiguities in the situation to cover for a colleague.

It's not just the 100mg dose. It's the 100mg dose for a 9lb cat, twice a day. When I have gotten gaba for my cats, the vet mentioned that she saw cats who had worked their way up to much higher doses than that, even, so I don't doubt that 100mg is a "common dose" in some sense. It's just not a conservative starting dose, and you weren't given instructions about what signs to look for with respect to an overdose.

You aren't trying to get that vet fired or sanctioned. All you are asking is for some assurances that the vets at Banfield will be more aware of possible consequences in their future prescribing. I don't think that's unreasonable.
 
They did ask her weight, and I told them how often she received it. One person said the formulary was 10mg/kg (which is still freakin 40mg) but 100mg for a cat was the standard. And that I should not be reporting anyone to the state board because it's not an overdose. I suppose I shouldn't have asked them but I assumed they would have acknowledged the error. One person said they give their 6lb cat 100mg daily and shrugged it off. But clearly my personal vet knew the dangers of it? So we're not just a bunch of crazy cat ladies on the internet.
 
Panic said:
One person said they give their 6lb cat 100mg daily and shrugged it off. But clearly my personal vet knew the dangers of it? So we're not just a bunch of crazy cat ladies on the internet.
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No. They're just being defensive.

Again, I was told that there's a lot of variation in ongoing dosage with gaba. Different cats (or people, for that matter) react differently to it. The fact that one person there has a cat that tolerates 100mg daily (note: not 200mg daily!) is irrelevant.

The Banfield vet may have been going by experience that most cats can tolerate higher than the formulary dose, and seeing that Panic was in pain, went with that. And most of the time, it might have worked. But they need to know that if they're going to do that kind of thing, they have to make sure that the pet parent is fully informed of the fact that it's a higher dose than formulary so they can give consent, and fully informed of what to look for with an overdosed pet in case it goes wrong. Nothing is perfect or guaranteed with either human or veterinary medicine, but this kind of adjustment is how you make it better going forward.
 
Thank you Nan. They were honestly making me feel like I didn't know what I was talking about.

I still don't understand why if formulary dose is 10mg/kg then why it's a "standard" to double a dose. 100mg would be adequate for a 22 lb cats ... an average cat is only 10 lbs??
 
No idea why. My wild guess is that 99% cats tolerate the higher dose (and may even need it for real pain relief), but the formulary dose is set conservatively to account for the 1% of cats who, like Panic, react more strongly. And the vets on the forum have never prescribed a pain regimen (multiple doses) to a cat in the 1%, or 0.1%, or whatever it is. But the formulary was set that way for a reason.
 
Could the formulary be found online anywhere? I couldn't find anything.

Agreed, and it's so weird because everyone's vets here seem to be aware because I couldn't find anyone here that was giving 100mg for anything. It seemed they were all either being very cautious or following the formulary.
 
I couldn't find anything "official" either from google, just a lot of repetition of the 5-10mg/kg dose in non-technical articles. Tomorrow after a good night's sleep I'll look again, rack my brain for other (non-google) approaches to look, but it occurs to me that maybe the fact that it's an off-label application means that there may not be a rock-solid document out there... Sigh.

As for the 100mg, I mentioned that Amber got that as a single dose before vet visits. So that's one example, but she was 18lbs, and it really sedated her-- no adverse effects, but for her, it was a substantial dose.
 
I found some formularies but they require a subscription to access so I couldn't check it. :/
I personally didn't find anything that specifically said that an overdose of gabapentin could cause respiratory failure (though my nurse friend said it can), but complications from pancreatitis could. An overdose so severe she was essentially unresponsive and causing hypothermia could have provided complications I suppose. Ugh. I just want my cat back.

Ah that's right, but an 18lb cat would be more closely following the formulary range at least.
 
From Plumb's Veterinary Drug Handbook (2008 edition), pp. 415-417. Do take note that this information is 12 years old.
I copied and pasted from a PDF. I cleaned it up a bit but there are still a few line separating hyphens and capitalizations I have not done. Sorry, recently out of hospital (not virus related) and not quite back on my feet yet. The information may not look right in places but should be readable.
p. 415
gabapentin

(gab-ah-pen-tin) Neurontin® ANTIcONvuLSANT; NeuROPAThIc

PAIN ANALGeSIc

prescriber Highlights

May be useful in dogs & cats as adjunctive therapy for refractory or complex partial seizures or the treatment of pain

Caution in patients with diminished renal function, but dogs partially (30–40%) metabolize the drug (humans do not)

Avoid use of xylitol-containing oral liquid in dogs

Sedation most likely adverse effect, but adverse effect
profile not well-defined for animals

Expense may be a significant issue, but may decrease as generics are now available

uses/indications

Gabapentin may be useful as adjunctive therapy for refractory or complex partial seizures, or in the treatment of chronic pain in dogs or cats.

pharmacology/actions

Gabapentin has analgesic effects and can prevent allodynia (sensa- tion of pain resulting from a normally non-noxious stimulus) or hyperalgesia (exaggerated response to painful stimuli). It also has anticonvulsant activity. The mechanism of action of gabapentin, for either its anticonvulsant or analgesic actions is not understood. While gabapentin is structurally related to GABA, it does not ap- pear to alter GABA binding, reuptake, or degradation, or serve as a GABA agonist in vivo.

pharmacokinetics

In dogs, oral bioavailability is about 80% at a dose of 50 mg/kg. Peak plasma levels occur about 2 hours post dose. Elimination is primarily via renal routes, but gabapentin is partially metabolized to N-methyl-gabapentin. Elimination half-life is approximately 2 – 4 hours in dogs. No pharmacokinetic data for cats was located. In humans, gabapentin bioavailability decreases as dosage increas- es. At doses of 900 mg/day, 60% of the dose is absorbed. Percentage absorbed is reduced as doses are increased to a minimum of 27%

(p. 416 gabapentin)

of the dose being absorbed when 4800 mg/day is administered. Presence of food only marginally alters absorption rate and extent of absorption. Gabapentin is only minimally bound to plasma pro- teins; CSF levels are approximately 20% of those in plasma. The drug is not significantly metabolized and is almost exclusively ex- creted unchanged into the urine. Elimination half-lives in humans are approximately 5 – 7 hours.

contraindications/precautions/Warnings

Gabapentin is considered contraindicated in patients hypersensi- tive to it. Because gabapentin is eliminated via renal routes (practi- cally 100% in humans), it should be used with caution in patients with renal insufficiency; if required, dosage adjustment should be considered. In dogs, the drug is also metabolized (30 – 40%) of a dose, so dosage adjustment may not be required in dogs with mild to moderate renal dysfunction.

In general, avoid the use of the commercially available human oral solution (Neurontin®) in dogs as it reportedly contains 300 mg/ mL xylitol. As the threshold dose that can cause hypoglycemia in dogs is approximately 100 mg/kg, doses of up to 15 mg/kg in dogs using the solution should be safe, but further data is needed to con- firm this. Additionally, xylitol may be hepatotoxic in dogs. Doses of 500 mg/kg of xylitol are currently thought to be the threshold for this toxicity, but there have been anecdotal reports of it occurring at much lower doses. In cats, at the dosages used presently, xylitol toxicity does not appear to be a problem with gabapentin oral solu- tion, but use with caution.

adverse effects

Sedation is probably the most likely adverse effect seen in small ani- mals. Starting the dose at the lower end of the range and increasing with time, may alleviate this effect. In humans, the most common adverse effects associated with gabapentin therapy are dizziness, somnolence, and peripheral edema.

Gabapentin was associated with an increased rate of pancreatic adenocarcinoma in male rats. It is unknown if this effect crosses into other species.

Abrupt discontinuation of the drug has lead to withdrawal-pre- cipitated seizures. In humans, it is recommended to wean off the drug when it is used for epilepsy treatment.

Reproductive/nursing Safety

In humans, the FDA categorizes gabapentin as a category C drug for use during pregnancy (Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans; or there are no animal reproduction studies and no adequate studies in humans). At high dosages (at or above human maximum dosages), gabapen- tin was associated with a variety of fetotoxic and teratogenic effects (e.g., delayed ossification, hydronephrosis, fetal loss) in rats, mice and rabbits.

Gabapentin enters maternal milk. It has been calculated that a nursing human infant could be exposed to a maximum dosage of 1 mg/kg/day. This is 5 – 10% of the usual pediatric (>3 yrs old) thera- peutic dose. In veterinary patients, this appears unlikely to be of significant clinical concern.

overdosage/acute toxicity

In humans, doses of up to 49 grams have been reported without fatality. Most likely effects include ataxia, lethargy/somnolence, di- arrhea, etc.

The commercially available oral solution contains 300 mg/mL; doses of 0.33 mL/kg may cause hypoglycemia or liver toxicity in dogs.

There were 256 exposures to gabapentin reported to the ASPCA Animal Poison Control Center (APCC; www.apcc.aspca.org) during 2005 – 2006. In these cases 211 were dogs with 13 showing clinical signs and the remaining 45 cases were cats with 11 show- ing clinical signs. Common findings in dogs recorded in decreasing frequency included lethargy, ataxia, sedate, vomiting and bulging eyes. Common findings in cats recorded in decreasing frequency included ataxia, lethargy, bradycardia, depression, and mydriasis. Treatment is basically supportive with general decontamination procedures including emesis, activated charcoal, and cathartics. The drug can be removed with hemodialysis.

Drug interactions

The following drug interactions have either been reported or are theoretical in humans or animals receiving gabapentin and may be of significance in veterinary patients:

antaciDS: Oral antacids given concurrently with gabapentin may decrease oral bioavailability by 20%; if antacids are required, separate doses at least 2 hours from gabapentin

HyDRocoDone: Co-administration of gabapentin and hydrocodone may increase the AUC (area under the curve) of gabap- entin and increase the efficacy and/or adverse effects of the drug. Gabapentin can reduce the AUC of hydrocodone, potentially re- ducing the drug’s effectiveness.

moRpHine: May increase gabapentin levels

laboratory considerations

There are reports of gabapentin causing false-positive urinary protein readings on Ames N-Multistix SG dipstick tests. The use of a sulfosalicylic acid precipitation test to determine presence of urine protein is recommended for patients receiving gabapentin.

Doses

DogS:
For ancillary therapy of refractory seizures:
a) 10 – 30 mg/kg PO q8 – 12h (Podell 2006a)
b) 25–60 mg/kg/day PO divided q6–8h, the author initially uses 10 mg/kg PO q8h. (Dewey 2005b)
c) 10 – 30 mg/kg PO q8h. note: expensive and of limited benefit (Berry 2003)
As an analgesic:
a) For adjunctive treatment of chronic or cancer pain: 3 mg/kg PO once a day (Lascelles 2003)
b) 1.25 – 10 mg/kg PO q24h (once daily) (Hardie 2006)

catS:
For ancillary therapy of refractory seizures:
a) 5 mg/kg PO three times daily (Pearce 2006b)
b) 5 – 10 mg/kg PO q8 – 12h (Podell 2006a)
c) 10 – 30 mg/kg PO q8h (note: expensive and of limited benefit) (Berry 2003)

As an analgesic:
a) 1.25 – 10 mg/kg PO q24h (once daily) (Hardie 2006)
b) For adjunctive treatment of chronic or cancer pain: 3 mg/kg PO once a day (Lascelles 2003), (Hardie, Lascelles et al. 2003)
c) For adjunctive analgesia associated with neuropathic pain:
While suggested range in cats is 2.5 – 5 mg/kg PO q12h, this author starts at 5 mg/kg and increases (up to 10 mg/kg) if no effect seen in two hours. May be a higher requirement in cats for post-seizure or CPR vocalization and thrashing. Wean off slowly or patient may experience worse pain. Reduce in renal insufficiency. Usually the limit of dosing is reached when pa- tient is sedated. (Mathews 2006)
(p. 217)
monitoring

note: Gabapentin serum levels are not monitored at present.
Clinical efficacy and adverse effects should be monitored.

client information

Clients should report any significant adverse effects such as ataxia or hypersomnolence
 
Thank you SO MUCH, Red. I saw this but couldn't access it due to the subscription. Also hope you feel better soon! :bighug:

Red & Rover (GA) said:
As an analgesic:
a) 1.25 – 10 mg/kg PO q24h (once daily) (Hardie 2006)
b) For adjunctive treatment of chronic or cancer pain: 3 mg/kg PO once a day (Lascelles 2003), (Hardie, Lascelles et al. 2003)
c) For adjunctive analgesia associated with neuropathic pain:
While suggested range in cats is 2.5 – 5 mg/kg PO q12h, this author starts at 5 mg/kg and increases (up to 10 mg/kg) if no effect seen in two hours.
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This right here is exactly what I needed. I'm printing it out and hanging onto it.
 
I am going to call them directly today after work and request a sit down between the vet, manager, and I. I feel a lot more comfortable having a copy of the formulary (both old and new edition!). They need to know that it was set with all cats in mind and be pointed out that they were giving the high end of sedation doses and doubling it to twice a day to boot.
 
I finally got a hold of the manager today. The secretary was a little snotty with me but whatever.

At first she said that my vet never sent her Panic's health record (which wouldn't surprise me), but then insinuated she thought she was just going to talk to her team about it and that be it, even though she said she was going to call me back. She said the vet was devastated to hear about Panic but that she had given that dose before with no problems. She (the manager) also said she didn't really think the gabapentin was the cause for Panic's death. I said I couldn't say for certain either but it was still an overdose. I said I had her health record and asked to sit down and talk with them both and at first she said yes but then asked if I could email it to her. At this point I'm emotionally exhausted and just want it all to be over. I sent her records over along with copies of the formulary that Red so awesomely found for me and wrote this:

Kim,

I have attached Panic's health record for the day she was admitted for the gabapentin overdose. Dr. Nixon noted that she was given 100mg where the dose should have been 30mg.

Just so you have the whole story, Panic went off her food on Sunday the 3rd and was showing signs of nausea. I gave her ondansetron that night and took her to Dr. Nixon first thing Monday morning, as a diabetic cat going off their food means trouble. They ran bloodwork and sent her home with a cerenia injection. She still wasn't eating for me and I suspected pancreatitis. Tuesday morning I asked for ketones to be checked and a SNAP fPL test but they did not have any, hence why I went to Banfield. Tested positive for pancreatitis, tested positive for ketones (from Dr. Nixon). I gathered at-home supplies to treat her (fluids, appetite stimulant, cerenia tablets, critical care food, and still had ondansetron). I requested buprenorphine but she did not have the oral kind on-hand, so I requested gabapentin until it arrived. She did not have it in a small enough dose so she recommended me going back to Banfield for it.

I was aware of the side-effects of gabapentin, ataxia and "stoned" effect which she definitely had. By Wednesday she was acting extremely sedated and difficult to assist feed. Well after midnight I checked on her and thought she had died. She was completely unresponsive and I couldn't find any indication of breathing. After several minutes of sitting with her I detected the faintest hint of her chest rising, I kept her warm and unfortunately could not get a hold of Magnolia (I thought they were 24 hr) so I just had to wait for my vet to open at 8:00.

During this time I had left messages with both my vet to call the moment they arrived and Diabetic Cats In Need (DCIN), an organization that helps caretakers and sugar cats. I am also a member of a feline diabetes group with members who have/had diabetic cats for many years. They had been helping me with Panic in general and at present time her pancreatitis. Someone asked me what the gabapentin dosage was for her and they pointed out that she had been given way, way too much for her size. By this time her breathing was better and she was attempting to get up for water, though still heavily sedated and experiencing ataxia. DCIN got back with me and were also upset at the gabapentin dosage and insisted I take her in the moment the vet opened.

Dr. Nixon told me shortly after I brought her in that she had very low body temperature from the overdose and sounded surprised at the dosage amount as well. She also mentioned that cerenia and ondasetron together were not ideal, though the caregivers helping me (many of which have treated chronic pancreatitis for their kitties) pointed out that they work well together because they address different issues. Her plan that morning was to get the body temperature back up first and foremost. She also tested negative for ketones by then. It was a couple hours later that she called and said that while they'd gotten her body temp back up, she'd gone into respiratory failure.

I am in no way saying that the gabapentin caused her respiratory failure. Complications from pancreatitis can, and it's possible the dose caused those complications, but I can't say for certain. I am obviously heartbroken that she didn't make it but I do not in any way think the dose was given with the intention to harm. Many cats are sensitive to it however, and Plumb's Veterinary Drug Handbook starts at a very conservative dose for those few cats that need it.

I have attached a copy of both the 2008 and 2018 editions indicating for pain, the dose should start at 3mg/kg once daily and if required, go up to 5-10mg/kg. Panic was a 9lb/4kg cat. For cats needing sedation due to anxiety, 50-100mg/cat is ideal. Panic was prescribed 100mg every 12 hours, making it 200mg daily.

Panic is gone, but I wanted this potential risk pointed out for the sake of other cats that can only handle the starting dose given on the formulary. We have a saying we use in the feline diabetes community: Every Cat Is Different. While 100mg may be normal (and needed) for a lot of cats, every cat is different.

I harbor no ill will towards your team. Human nature comes with errors. We lose lives, but we also extend them.

- Elizabeth G / Panic's mom
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Hopefully I wasn't too preachy/dramatic, but I'm a mess still.
I think I'm done with it. I'm tired. I don't really expect a reply but whatever.
 
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Okay, last update...

The chief vet from Banfield called me today and said she looked at Panic's case. She said she called a toxicologist at Pet Poison Hotline and explained the case and ultimately said there were no instances of respiratory failure with gabapentin. She did say the dose was on the higher end and that she would keep it in mind in the future. She also said she thinks Panic was in DKA + pancreatitis and the DKA was what possibly caused her death. I don't know about that. She said she wouldn't have used gabapentin and said that in her notes it said I refused bupe from Banfield (honestly I don't remember that, it was probably when she was tested positive for pancreatitis and she was talking about treatment options but I wasn't planning on using them for treatment, just my own vet. I never even thought to see if they had oral bupe). Ultimately she doesn't think the gabapentin had anything to do with it and wanted to point out that my feline diabetes community "were not vets" and I made sure to tell her FDMB had more experience than a lot of vets and don't claim to be replacements for them. I did appreciate her checking with a toxicologist though.
 
Nan & Amber (GA) said:
I just want to ask, based on what tests/data?
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Apparently just based on the fact that she had ketones on Tuesday and her frustosamine was 801. I told her I wasn't under any impression she had DKA, I mean, no one here mentioned it, no vets did. She tried to tell me the FRU test could have been high because she might have been going up during the night but that would be the opposite of what usually happens lol. I told her the highest reading I had that week was 423 and she was like "yeah that will throw a FRU test off" soooo idk.
 
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