Old cat with CRF not eating or drinking

saraberaNovember 30, 2012

I have a 19 year old cat (Ziggy) that was first diagnosed with CRF 6 years ago. We have had a lot of ups and downs, I almost put him to sleep a couple of times years ago. I realize every day now is a bonus day. He is having a lot of problems right now, but the vet feels that his numbers are not too bad (BUN 75, Creatinine 3.5) and that he can get back to his cranky old self.

About three weeks ago I took him to the vet for usual checkup and blood draw. Vet said he was slightly dehydrated and wanted to start doing Sub Qs. I put off picking up the fluids for about 1 1/2 weeks (bad) because he was doing fine, but he became even finickier about eating and wasn't getting much down, so I started him out. He hates the Sub-Qs. Three days later he was not eating at all (even roasted chicken, his favorite) and not getting out of bed at all. Back to the vet, he showed me how to syringe feed him, and sent me off with more meds (I believe there is about 9 right now, including vitamins). Ziggy did well with the syringe feeding, but three days went by and he wasn't getting out of bed, and quit drinking. I went back to the vet and picked up antibiotics and talked with him about possible euthanasia at home. Now two days later, Ziggy is 200% better, following me around, even went outside to sit for a bit. He is licking up about 1 tab. of food at a time but still not drinking at all.

This week has been an emotional roller coaster and I am just plumb worn out. Does anyone have an idea of what to expect at this point? My husband seems ready to put him to sleep if he doesn't start feeding himself and drinking. I'm willing to do whatever it takes to keep him around as long as he is not suffering. Has anyone gone through a similar scenario, and what would you do?

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I haven't been through it with a cat but I have been there with two of my dogs. You said the vet gave him some more meds, so I'm wondering if you vet has just put him on an antacid or anti nausea meds? that would explain his turn around if he has, but also if he had an infection he may be feeling better from the antibiotics. But often what happens with crf is the stomach becomes inflamed and acidic, and it really puts them off their food, so it's important to try and keep the stomach settled with things like antacids, if you suspect he's nauseous then getting that under control is important too. Another thing I found helpful is to elevate the food dish so they don't have to lean over when they eat, it seems to help stop the acid from coming up when they eat which can be enough to put an animal off eating, but with crf when they go off their food, stomach acidity is a very common cause.

What about diet? are you keeping him on a lower protein food? I've seen it make a huge difference when my last dog had crf. She went from being very sick to springing back to life on the hills science diet k/d. Some people think the kd is a big scam but I've seen what a huge difference it made for my dog and she lived another 15 months very happy and full of life which really surprised us and the vet. The feline canned one is very wet so it will help him get some fluid in as well, I would avoid kibble though. I think you should at least try it and see if it makes a difference to how he feels

This post was edited by trancegemini_wa on Sat, Dec 1, 12 at 6:44

    Bookmark   December 1, 2012 at 6:32AM
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It's very difficult to make recommendations without knowing exactly what you're doing for your boy right now. Could you please post a complete list of all meds/supplements/treatments you're giving him now (including subQ fluids), and in what doses/frequency? Also, it would be very helpful if you could post his most recent lab results in their entirety (including all lab values and reference ranges). That would help us to offer relevant suggestions based on your cat's current condition and treatment protocol.


    Bookmark   December 1, 2012 at 10:44AM
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Thanks so much for your feedback so far. I just came from a long talk with the vet, and his main concern at this point is that Ziggy is not eating much. We are going to back down on the Sub-Qs a bit and see if he starts drinking. I got a copy of the blood test taken on 11/10/12 and here are the results that are not normal: (normal range in quotes)
Weight is 6 pounds.

BUN 75 (10-35)
Creatinine 3.5 (1-2)
Potassium 3.7 (4-5.8)
CO2 14 (17-24)
Phosphorus 10.9 (3.5-6.1)

There are some others that are slightly off, let me know if there are any others that you would like to know.

Right now here are his medications/supplements:
Enalapril (1/2 pill) been on this forever
Prilosec--2grains once/day, just started
Phosphate binder--1ml/day, just started
Potassium (Tumil-K) 1/2 tsp/day, just started up again
Clavimox 2ml/day started 3 days ago, made the difference!
Epakitin 2 gms/day
Pet-tinic 1/2 ml? once/day
Sub-Q hydration--was doing 120mls every day, we are now going to cut back and see if he starts drinking
Syringe feeding--have been doing 3x/day (1 syringe)
Hairball remedy--thinking about starting for constipation

Whew! I think that is it. We do put his food on a raised platform. He is a terribly picky eater (wasn't always like that at all), and getting him to eat anything has always been out hightest priority. We rotate out small cans of the food he seems to like. Hates everything from Vet except Royal Canin A/D and R/S.

    Bookmark   December 1, 2012 at 5:41PM
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Oops, forgot to mention, the vet thinks he either had a UTI infection or it could be his teeth (which are horrible!). That is why he responded to the antibiotics.

    Bookmark   December 1, 2012 at 5:56PM
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There is a CRF support group where you can post your labs and meds and other info and they will help you and give you input on his condition. There is a lot of traffic there so you will get responses quickly. I can't post the link here-could you email me by clicking on my name? He seems to be getting better and hasn't given up! An informal way to judge hydration is to feel his gums-they should feel slick and wet, not thick and sticky.

    Bookmark   December 2, 2012 at 1:29AM
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I guess they changed the user page


    Bookmark   December 2, 2012 at 1:32AM
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Lisa, are you talking about the group affiliated with Tanyas CRF website? I am actually registered there, and get the digests, but I can't figure out how to post! and the format is really confusing to me. I'll give it another try.

Ziggy is doing great today!! I am so thrilled, he is eating, a little bit at a time, but often. He is drinking just a bit, nothing like he used to, so I am a bit concerned that he's getting enough liquids. I think the phosphate binders and vitamins are really helping as he looks a lot better.

    Bookmark   December 2, 2012 at 2:47PM
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The bloodwork values you provided, along with the list of meds/supplements offer several clues regarding Ziggy's limited appetite. It would be helpful to see ALL of his lab values, including those within the reference ranges. However, based on the few blood values in your post, I would assume that the primary factor in Ziggy's reduced appetite is his high phosphorus (which can REALLY destroy appetite). Dehydration and low potassium can also kill appetite. Assuming your vet prescribed Prilosec for excess stomach acid and Pet-tinic for anemia, both of those conditions can also kill appetite. So, there are LOTS of reasons here for Ziggy to lose interest in food.

Aside from the Epakitin, which phos binder are you using, how many mg/day (ml doesn't help without knowing the strength per ml), and how much does Ziggy weigh? If it's aluminum hydroxide (which is the most effective of the phos binders, and the one that Ziggy really should be taking), you need to be aware that al hyd can be very constipating. If you are giving al hyd, you should also be giving a laxative like Miralax or lactulose (I prefer Miralax) AND daily subQ fluids to prevent constipation. Nothing strips appetite and makes a cat feel sicker and more painful than constipation, so it's extremely important to prevent it from occurring. BTW, the iron in Pet-tinic is also constipating.

Ziggy should be receiving fluids daily, because dehydration with also make him extremely sick, weak, and inappetant. What brand and size needles are you using? What type of fluids are you using? Is anything being added to the fluids? Are you warming the fluids before administration? Are you restraining Ziggy during fluid admins, and if so, how? There are a lot of tips and tricks to making fluid admins easier and even enjoyable for your cat. Let me know the answers to the questions above, and I can help you develop a strategy that will likely work for you and Ziggy.

I'm surprised that your vet prescribed Prilosec instead of Pepcid AC or Zantac 75, which are the commonly used acid blockers for CRF cats. I'd be interested to know why your vet opted for Prilosec.


    Bookmark   December 3, 2012 at 11:03AM
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Thanks so much for your input. Ziggy is continuing to do well and I want to keep up his good progress. There are like 30 different items on his blood panel, but here are a few more that are off.
Platelet count 246 (300-800)
Lymphocytes 710 (1500-7000) from infection?
Osm (osmotic?) Calc 317 (270-310)
Amylase 2338 (500-1500)
RBC looks like 6.11 (6-10) hard to read
T4 (thyroid) 1.4 (1.8-4.5) he has always been a bit low since I had his thyroid irradiated years ago.

I'm not sure about the strength of the binder, since the vet gave it to me in a plain bottle, but it is apparently aluminum hydroxide as he said it is the same ingredient as Mylanta. Ziggy used to be on lactulose but it was making him throw up so I had to quit. I'll have to do some more research on Miralax.

I'm using Ringers solution, size 18 needle to make it go fast. I've started warming the solution and it definitely helps a bit. My husband is helping me to hold the cat, which is difficult because he is terrified of needles and getting bit! I did two cats before with sub-Qs every other day, and it was a piece of cake, by myself. Ziggy is usually fairly cooperative so I don't know what is going on with that. Perhaps I should try a restraint bag?

I'm not sure why the Vet is using Prilosec. Is it normal for a CRF cat to be on an acid blocker all the time?

    Bookmark   December 4, 2012 at 12:21AM
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Yes-as far as I know just about all if not all of them are. We use the pepcid.

    Bookmark   December 4, 2012 at 12:49AM
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Here's my favorite site for interpreting feline lab results. Click on the name of each lab value of interest, and it'll download a small pdf file that explains the primary implications of that particular lab value:

lab value explanations

If Ziggy dislikes the liquid al hyd that your vet provided, you can purchase it in a tasteless powder form that is easily mixed into food at the following link:

aluminum hydroxide powder

At the same website, you can purchase the needles that are most popular with CRF caretakers (Terumo Ultra Thin Wall 20 ga.). Terumo needles are considered by many (myself included) to be better manufactured and sharper than the Monoject needles that most vets use. The superior sharpness and smoothness of Terumo needles seems to be more comfortable for cats. The 20 ga. Ultra Thin Wall Terumos have a flow rate that is almost equivalent to the larger, more uncomfortable, 18 ga Monojects, as well.

You can also purchase IV lines at the same site.

In case you're not aware, you can purchase Ringer's very inexpensively by the case if you call around and price shop at your local pharmacies. You probably won't find any pharmacies that keep it in stock, but they should all be able to order it for you overnight. You'll just need a prescription from your vet. I can purchase a case of 14, 1000ml bags of Ringers for $23/case from my local Target Pharmacy.

Lactulose and Miralax are both osmotic laxatives with similar action in the gut. Lactulose, however, may cause digestive upset in lactose-intolerant animals (which most cats are), whereas Miralax will not. Miralax, being a nearly tasteless crystalline powder, is MUCH easier to administer than Lactulose, as well. It is easily mixed into canned food and is undetectable to most cats. Like Lactulose, Miralax is a dose-to-effect drug, meaning that you can adjust the dose up or down to maintain optimal stool consistency. But like Lactulose, Miralax is only effective in a properly hydrated animal, which is one more important reason to be consistent with subQ fluids.

From your description, I have to assume that Ziggy is responding to your husband's nervousness during fluid admins. If I were you, I would kindly dismiss your husband from fluid duty and handle it yourself. It's also extremely important to warm the fluids before admins, as room temp fluids can badly chill a cat and make him extremely uncomfortable. If you'd been using room temp fluids on Ziggy and just recently started warming them, he may still be anticipating the chill of unwarmed fluids. Just give him a little more time to trust that he'll be getting a warm internal shower instead of a cold one from now on.

I have found that the less restraint I use, the more cooperative my cats are during fluid admins. I do admins on diningroom chairs by a large window. I use my body and the chair backs to block the cat's movement off of the chairs without actually having to hold the cat, while the window helps to distract the cat a bit during the admin. I'll post a pic of my setup if you'd like to see it.

It's very common for CRF cats to have problems with excess stomach acid, so many of them do take an acid blocker. As I noted earlier, Pepcid AC is the most commonly used med for this purpose. I use Zantac 75, instead, because it has fewer potential drug interactions than Pepcid. But Zantac is a pain in the neck to cut into 1/8's. I don't know of anyone who uses Prilosec, which is why I'd be very interested to know why your vet chooses to use it. If he knows of any studies of Prilosec's use in CRF cats, I'd love to read them. We CRF caretakers are always on the lookout for potential improvements in our management protocols.


    Bookmark   December 4, 2012 at 3:19AM
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Thanks for the link--I filled up a "cart" and got to check out before I realized that I need a prescription even over the internet! Dang, another trip to the vet. I'll save up the questions, including the prilosec and Miralax for him.

The one thing that I am really confused about--now that Ziggy is eating on his own quite well, I'm not sure how to "dose" his phosphate binder. I was putting it in the syringe food, and I still give him 1/2 a syringe morning and evening with his meds mixed in, but I need to get it into his canned food as he won't eat low phosphate canned diets. (He's eating the KD kibble somewhat, unbelievably). Isn't there some chart for how much to put into a 3 oz. can or a 5.5 oz can? Is it okay to mix it up in the can and keep in the fridge? He eats very little at a time (but often), so it's impossible to "dose" every "meal".

Now that we've cut back to twice a week, Ziggy is being a bit more cooperative. I tried to do the fluids myself, but couldn't keep him in place. I do think it would be helpful to get my husband out of the picture, he doesn't seem to like it either.

    Bookmark   December 6, 2012 at 12:06AM
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Hmm. What did you need a script for, the al hyd? I believe Thriving Pets will accept phone prescriptions, which would save you a trip to the vet (assuming your vet is willing to call in the script).

As far as dosing al hyd is concerned, I think I'd try this - measure out his full daily dose of al hyd in the morning. Then each time he eats throughout the day, mix a little of the daily dose into each meal. If you know the average number of meals he eats during the day, you can do a rough calculation of how much of the daily dose you should mix into each meal. Whatever is leftover at the end of the day gets mixed into the last meal. There is no standard dose of al hyd per oz of food. Al hyd is dosed based on Ziggy's weight and current serum phosphorus level. The following link on Tanya's site will provide you with information and recommended dosing guidelines for al hyd: aluminum hydroxide.

I just spent some time going through Ziggy's med list, checking for potential drug interactions. Here's what I found:

Enalapril can cause potassium retention and increase the risk of hyperkalemia (high potassium) in cats receiving potassium supplementation. Monitor Ziggy's serum potassium level closely while taking Tumil-K.

Prilosec may decrease the absorption of both the iron and cyanocobalamin in Pet-tinic.

Hairball remedies can interfere with the absorption of fat-soluble vitamins, so they should be given infrequently on an as-needed basis only, and between meals.

I've got to go get my 4-leggeds fed for the night, so I'll have to continue this tomorrow.


    Bookmark   December 6, 2012 at 1:48AM
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Help! I need a hail mary. My 14 year old indoor cat is isolating, not eating and drinking. Giving her hills nutrient dense food by syringe with antibiotic and appetite stimulant. Not working. Vets theory is it is her heart or cancer. Her blood showed an elevated ck level and the vet heard a slight heart murmur. She has never been sick a day in her life. She is a beautiful animal. HELP!!!!

    Bookmark   December 6, 2012 at 10:32PM
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OK, let me explain how I administer fluids and see if any of my strategies might work for you and Ziggy. Here's a photo of my fluid setup:

I sit across the fronts of the chairs with my back facing the lefthand wall and legs stretched forward across both chairs toward the window. I place the cat between my legs and the chair backs. In that position, I can raise or lower my knees, if necessary, to help keep the cat from stepping or jumping over my legs. Between the chair backs, the walls, and my body, the only potential escape route for the cat is forward toward the window, and I can cup one of my hands gently around the cat's chest to prevent that escape. The cat can, however, move forward and back on the chairs between my legs and the chair backs. That freedom of movement diminishes the cat's inclination to fight restraint.

The most important element in keeping my cats compliant during fluid admins is properly warming the fluids. I know I mentioned this in an earlier response, but it bears repeating because it's extremely important to the cat's comfort. You have to be very careful not to get the fluids too warm, however. Make sure fluids are wrist-comfortable (like baby formula) before admin.

With your fluid admin experience, you're probably already aware that different cats have different preferences during the procedure. Some enjoy being stroked, scratched, or groomed during admins. Some like being fed. Some like listening to soft music. Some want to be left completely alone and have you sit there like a stone until the admin is finished. You just have to find the strategy that works best for Ziggy.

Oh, one more thing. Many cats start to get uncomfortable if more than 100 ml is injected into the same spot. The fluid pocket just gets too large. If you are giving more than 100 ml per admin, it would be best to split the amount into two admins on separate days, instead. Not only will that keep the fluid pocket smaller and more comfortable, but it will also keep Ziggy more evenly hydrated, which will make him feel better overall.


    Bookmark   December 7, 2012 at 8:35AM
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In order to get a better idea of what may be causing your girl's illness, it would be very helpful if you could post ALL of her lab values (see the way sarabera posted her cat's labs above). We need to know which lab values were checked and what the results were. That way, we can make suggestions and offer insights that will hopefully be relevant to your cat's current condition.

If your cat isn't eating or drinking on her own, you will need to provide both food AND fluid to keep her nourished AND hydrated. Your vet can teach you how to administer subQ fluids at home, as sarabera and I have discussed above.


    Bookmark   December 7, 2012 at 9:00AM
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I hope your cat is doing better by now. With my cat it took a few days, even after we started the antibiotic, before he was beginning to eat, and even then it was a slow upward progression. As Laurie said, you need to get fluids in her, by IV at vet or sub-Qs, if she is not drinking. Please keep us posted.

Laurie, thanks so much for the info, and especially on drug interactions. I like my vet a lot, but I need to find a way to discuss all the issues with him, without being offensive. (I can only imagine what it would be like if one of my clients tried to correct something I had told them, or introduce a treatment I was not familiar with).
Unfortunately Ziggy is still fighting me horribly with the Sub-Qs. Tonight we had to cut it short. It is really hard to get a needle in him properly when he is all hunched up and wiggling. I think I am going to have to look into a restraint bag so I can do it without my husband helping. (He is still terrified of getting bit, or stuck with the needle) I'll get a prescription tomorrow, then I can order the new needles and other stuff online. I really appreciate the tutorial, and I'm sure others will benefit from the info.

    Bookmark   December 9, 2012 at 9:14PM
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Cats can tighten their skin so that it's as impermeable as steel when they get anxious. The trick is to just sit there and stroke, rub, or scratch him (particularly between the shoulder blades where you're going to insert the needle) until he relaxes and unhunches. Once you feel him relax, then quickly and smoothly insert the needle.

If Ziggy refuses to relax no matter how long you stroke, rub, scratch him, then I recommend buying a portable IV stand so that you can take it wherever he is. Wait until he's napping soundly, then take the fluids and IV stand to his location, sit down next to him, and quickly and quietly slip in the needle while he's sleeping/drowsy.

I find it's best to do fluid admins first thing in the morning. That way, the cat quickly learns that once the admin is finished, he is "safe" for the rest of the day and can relax without wondering if he's going to get stuck again.

As far as communicating with your vet is concerned, explain to your vet that you have joined an large online group of CRF caretakers who have provided you with information about management strategies that you'd like to discuss. If you have specific items you'd like to discuss, print out the information and take it with you to see your vet. Make sure your vet knows that you need to be able to partner with him to manage Ziggy's CRF, and that you are dedicated to learning as much about this disease and its various management strategies as possible. If your vet has Ziggy's best interest at heart, he will welcome your dedication, interest, and partnership.


    Bookmark   December 11, 2012 at 10:26AM
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I wanted to provide an update on my cat in case it might be helpful to others in the same situation. Ziggy is doing okay right now, it has been up and down. He was doing really well around Christmas time, then after the new year he quit eating again. I put him back on anti-biotics again, but he wasn't getting better. Then I put him back on acid blockers (pepcid AC this time) and he started to get his appetite back. (Due to a misunderstanding with the vet, I had stopped the acid blocker).Antibiotics are done now (apparently they can also suppress appetite). But he is still not eating as much as he should. Fortunately he is extremely easy to syringe-feed, and we have a system down now where he turns his nose to the syringe if he wants more, and turns away when he is full (so I don't feel like I'm forcing it down him). But I don't feel great about having to feed him, and before, I would have said this is when he should be PTS. He does not seem to be in pain or miserable though, he sits in front of the fire, and goes outside once a day for a while, so I will continue to take it day by day. I've come to terms with the fact that any day now I may have to put him to sleep.

Giving him the sub-q fluids has become MUCH easier. We are doing 100 mls twice a week. I purchased the cat restraining bag online (one with top zipper). Even though the bag is much too big, (I oversized it after reading the reviews), and he is able to sit upright inside the bag, he does not struggle at all and seems quite calm. My husband only has to help me get the bag fastened, then pet and talk to Ziggy, a much more comfortable job. I purchased the Terumo needles in 20 gauge and he doesn't even flinch when the needle goes in. I believe he has now made the connection between getting sub-qs and feeling better.

So to recap, the regimen is
Enalapril, 1/2 pill per day
Cosequin 1/2 capsule per day
Pet-tinic vitamins 1ml per day
Famotidine (pepcid AC) 2.5 mg per day
Phosphate binder mixed with any non kidney diet food (kind of have to guess at amt)
Miralax 1/16 tsp per day
Potassium (Tumil-K) 1/2 tsp per day on fluid days
I divide the medicines that are not pills into two groups (morning and evening). I take about a Tab of Science diet A/D or R/S and put it into the corner of a baggie, the medicines are mixed in and squished around, then I snip off the corner of the baggie and squirt it into the syringe (Monoject 412 with tip snipped down). This works GREAT for giving him meds and I wished I had tried it years ago.

So hopefully this is helpful for anyone on the roller-coaster that is a CRF cat. It is good for me just to put it all down in writing and start to put it in perspective. Of course I welcome any suggestions or input on his situation.

    Bookmark   January 20, 2013 at 3:41PM
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