Minou's treatment plan

[Karen & Angus(GA)]

Minou had her staples removed this morning and a blood draw for baseline liver values. Her weight was up 3 oz., so that appetite stimulant really worked. If I ever have to use it again, I will use only 1/8 tablet instead of 1/4. She is looking and acting normal.

Today she started amoxicillin, flagyl, and Pepcid A/C bid for the next 14 days to try to knock out the helicobacter. She starts denamarin tomorrow for liver support. She will start pred on Thursday. 20mg/day for the first 5 days, then 15mg for 5 days, then 10mg for 5 days, and 5 mg per day until liver enzymes are rechecked. Assuming it works, she will be on pred for life for the cholangiohepatitis and IBD. Plus she will get chlorpheniramine bid as needed for allergies.

Good thing she is a relatively easy cat to pill!

 

[Anonymous]

OMG karen, I'm afraid I have'nt kept up on minou's health issue's but wow, that certainly is a whole lot of treatment. the antibiotics and flagle won't help her appetite. at least did'nt mine when i was on them.
bless you for taking such good care of minou.
lori

 

[jt and trouble (GA)]

Wow that is some post! Most of it went right over my head...ok all of it. Sending prayers all goes well. :/
j.

 

[Jill and Remi]

Glad she is easy to pill and I hope she does better soon!

 

[Jess & Earl]

Hi Karen

I got your PM. I didn't comment on this post of yours because I think you're seeing an internist about all this, correct? And I assume s/he has experience that I don't have. But my $0.02, since I'm commenting anyway, is that it makes no sense to me to start the pred while she's getting the antibiotics for Helicobacter. You're trying to kill a bacterium while simultaneously trying to suppress the white blood cells that kill and clean up the killed bacterium ... I dunno why they don't want to wait until after the 14 day course is done to start the pred, because I gather her symptoms are not urgent.

Also, to me that seems like a big honking dose of pred to start with. How many kgs is Minou?

Speaking of symptoms, you'll kill me but once again I forget her symptoms. I'm sorry, I know I asked you for a reminder in another recent thread.

So about the Helicobacter. There is one feline vet who says she has stopped treating for Helicobacter when she finds it only on the surface of the biopsy (rather than burrowed more deeply in the stomach tissue), but generally speaking it is still standard to treat Helicobacter in cats with symptoms. Helicobacter has been linked to gastritis and hepatitis although the exact mechanism is unknown; it seems to promote inflammation which then gets seeded throughout the GI tract. Because of Minou's hepatitis, I'd be inclined to treat for this. Yes, she may reinfect (or more likely, have a resurgence of bacteria that escaped the first course of treatment) but you'll get to see if there is a big difference in her symptoms (assuming you don't start pred at the same time, another reason not to) and there may also be some benefit to breaking the cycle of inflammation, if Helicobacter is behind it. Does that make sense? If there were large quantities of the bacterium, cutting down the numbers could help as well.

I guess it also depends on how "gastric" her symptoms were. If she's a big time vomiter, that also puts a point on the "Should Treat It" board.

Is there any way you might be able to get the meds into one or two gelcaps to facilitate administration? You just said she's having a rough time with them, do you mean that she's getting the runs or you're having trouble giving them?

 

[Karen & Angus(GA)]

Thanks, Jess.

First, she really has had no clinical symptoms. She vomits an average of 1 - 2/week, but she has done that her entire life. What started this whole course of diagnostics is that her liver enzymes (AST/ALT) have been elevated for over a year and slowly creeping up. I don't have the exact numbers in front of me, but AST was around 250. So, she had an abdominal ultrasound, bile acids, and GI panel. The ultrasound showed no liver abnormalities, but slightly thickened intestines. The bile acids and GI panel were all normal. The IM's vet first recommendation was a trial "novel protein" diet. We did that for 7 weeks and her AST jumped to 700, and ALP was also elevated for the first time. So, she had biopsies. Biopsies showed cholangiohepatitis, lymphocytic-plasmacytic gastroenteritis, large quantities of helicobacter, and some hepatic lipidosis.

We had our treatment consultation Monday. The IM vet said the liver inflammation was moderate, and the IBD mild. So, she wanted to treat for helicobacter first, then start the pred. They drew blood for baseline liver values. We got a surprise in that AST/ALT/ALP had all returned to normal. I posted this message before we got blood work back. She now recommends waiting a week to start the pred and just starting and staying with the 5 mg dose (Minou weighs about 5.8 kg.) until we do a recheck in 6 - 8 weeks.

I gave her the first dose of Pepcid/amoxi/flagyl around 8 pm Monday, right after her meal. She vomited all the food and meds around midnight and drank some water. She vomited the water around 1:30 am and vomited blood tinged foam around 4:30 am. She then had a small amount of diarrhea at 8:30 am and again around 4 pm. All of this from just one dose. I suspect the flagyl because she had amoxi following the surgery with no problems.

Her IM vet only works M/W/F, but her tech contacted her for me. Her recommendation was to do only pepcid yesterday (Tues). Pepcid + amoxi today, and resume all three Thurs. Also, to give the amoxi and flagyl about 2 hours apart.

So, is there anything I can do to make this course of a/bs easier on her? How effective are the meds if she vomits them? She is relatively easy to pill. I am giving the pills in a pill pocket (just enough to coat the pills). The flagyl and pepcid are small enough to combine in one, so she will be pilled four times/day. I had a bit of trouble getting her to eat on her own after the surgery. I gave her one dose of mirtazipine and she has been eating since. Her weight has returned to her pre-surgery weight. She is being a bit picky and does not seem particularly hungry, so getting her to eat with each of the pills is a problem. I am adding FortiFlora to her food, but I am not sure how effective that is when followed immediately by a/bs.

 

[Jess & Earl]

Hi Karen

The IM vet said the liver inflammation was moderate, and the IBD mild. So, she wanted to treat for helicobacter first, then start the pred.

So she did not mean to start the pred while still on the antibiotics? That was what I had gathered from your first post.

We got a surprise in that AST/ALT/ALP had all returned to normal.

Kind of like how your hair looks great on the day you have a haircut scheduled :roll:

I suspect the flagyl because she had amoxi following the surgery with no problems.

She had oral amoxi in the hospital without issues? Or you gave her amoxi at home? Amoxi is much, much more likely to cause vomiting and diarrhea, so I'm surprised.

So, is there anything I can do to make this course of a/bs easier on her? How effective are the meds if she vomits them?

If she vomits them again, I'd call the IM vet and see about aborting or switching protocols. Has she vomited the solo ab + pepcid you gave today?

 

[Karen & Angus(GA)]

The IM vet said the liver inflammation was moderate, and the IBD mild. So, she wanted to treat for helicobacter first, then start the pred.

So she did not mean to start the pred while still on the antibiotics? That was what I had gathered from your first post.

She originally wanted to start the a/bs on Monday and the pred on Thursday because she wanted to wait 14 days from surgery before starting pred. She now wants me to start the pred next Thursday because of the digestive problems. So, yes, she does want me to give both at the same time, just give the a/bs a one week head start.

I suspect the flagyl because she had amoxi following the surgery with no problems.

She had oral amoxi in the hospital without issues? Or you gave her amoxi at home? Amoxi is much, much more likely to cause vomiting and diarrhea, so I'm surprised.

She had two days of injectible (or IV, not sure which) ampicillin in the hospital and three days of oral amoxi at home without any problems.

So, is there anything I can do to make this course of a/bs easier on her? How effective are the meds if she vomits them?

If she vomits them again, I'd call the IM vet and see about aborting or switching protocols. Has she vomited the solo ab + pepcid you gave today?

She has had two doses of Pepcid + amoxi today without any problems so far.