Nausea, vomiting and loss of appetite are some of the most common problems
in CKD cats.
There are a variety of possible causes, and a cat may have more than one
reason for showing these symptoms.
Fortunately, in most cases there are treatments which can help make the
cat feel much more comfortable, but in order to know which treatment would
work best, you need to know the most likely cause in your cat's case.
Excess stomach acid is one of the most likely culprits in
cats with creatinine over 3 (USA) or 265 (international), though it
can also be a problem in cats with lower creatinine levels.
There are a number of treatments that can help excess stomach acid.
If your cat continues to have problems despite being treated for excess stomach
acid and any other possible causes, there are other treatments available
which can help control nausea and vomiting.
Please note, excess stomach acid is not the same thing as
metabolic acidosis.
Unfortunately, there are a large number of possible causes of nausea,
vomiting and loss of appetite in CKD cats. It can therefore be confusing
trying to decide what might be the cause in your cat's case. To help you
narrow it down, I would scan through the list of symptoms on the
Index
of Symptoms and Treatments page to see if any of them look familiar.
.
Alternatively, the list below outlines some of the possible causes of nausea,
vomiting and loss of appetite. If you already know that your cat has a
particular problem, say, high phosphorus levels, you can click on the
appropriate link where you will find more information on other symptoms
associated with that condition, which may help you narrow down the cause:
Ask your vet to rule out any of these causes or to treat them if they are
present. Treating any that are present should not only stop the vomiting
and appetite loss and help your cat feel more comfortable, it may in some
cases (e.g. controlling high phosphorus levels) also help slow the
progression of the CKD.
(2011) is a presentation by Dr S Little to the 36th World Small Animal
Veterinary Association World Congress with a flow chart for
narrowing down the cause of the vomiting.
Toxins, Including Excess Stomach Acid
Even if you rule out or treat the above causes, your cat may still
continue to have problems with vomiting, nausea and appetite loss. In such
cases, the problem may be caused by toxins, particularly excess stomach
acid. Almost every CKD cat will have problems
with stomach acid at some point, so the chances are you need to read this
page even if your cat might have some of the above problems too. Take a
look at the list of symptoms below and see if they sound familiar - most
people find they do.
Gastrin is a gastro-intestinal hormone which stimulates the
secretion of gastric acid, which helps the stomach digest food. The
kidneys are responsible for the excretion of gastrin, but in CKD this
function may not work so well, resulting in the gastrin remaining in the
stomach and stimulating the production of too much gastric acid.
This excess stomach acid can make a
cat feel very unwell. In severe cases stomach ulcers may develop, which
may cause
gastro-intestinal bleeding.
Generally speaking,
cats with creatinine over 3 (US) or 265 (international) will need help controlling excessive stomach
acid.
Also, although BUN is not itself a toxin, there is a
correlation between it and other toxins which are less easy to measure.
Therefore, the higher your cat's BUN or urea level, the higher the overall
toxin level will be, and the more likely it is that s/he
will feel sick and vomit.
If your cat has relatively low kidney
bloodwork values (in the 2s or low 3s in US terms, 200-300 international)
but nevertheless seems to vomit a lot, I would ask your vet to rule out
pancreatitis.
There is no
test as such for excess stomach acid or other toxins, but these are
some of the symptoms you might see (though some of these may also be due
to other causes, as mentioned under each category):
Loss of
appetite is very common in CKD cats, and is often linked to excess stomach acid. Human
CKD patients have reported that
their sense of smell and sometimes taste are impaired; this is thought to
be caused by uraemic toxins, and probably occurs in cats too.
Cats who do
not eat are at risk of developing a potentially life-threatening condition
known as
hepatic lipidosis;
Mar Vista Vet
has more information about this. Therefore, it is important to try to find the cause of the inappetance and
treat it as quickly as possible.
Nausea
Nausea can
be hard to detect, though it is often manifested in a lack of appetite. The
cat may also lie scrunched up, looking uncomfortable.
CKD cats
often vomit. Vomiting
may be seen alone or in conjunction with the other symptoms in this
section. Many cats with excess stomach acid or uraemia vomit regularly
without treatment.
Sometimes
there may be blood in the vomit - bright red blood is fresh blood, whilst
older blood looks like ground coffee grains. This may be a sign of
mouth ulcers
or of
gastro-intestinal bleeding,
but you should contact your vet immediately if you see this symptom - our
George, a non-CKD cat, vomited old blood as the first symptom of severe
liver disease.
Cats who
vomit a lot are more likely to become
dehydrated.
There is a
difference between vomiting and regurgitation. Vomiting is usually
accompanied by a lot of abdominal movement, whereas regurgitation happens
suddenly and with less warning. Vomiting means the cat is emptying the
stomach, whereas regurgitation is where food has not yet reached the
stomach but is being ejected from the oesophagus more or less intact,
often because of eating too fast or hairballs. Regurgitation is often
sausage-shaped.
The American Association of Feline Practitioners
explains the difference and links to a number of sites, including
one with a video of a cat vomiting.
Cats who
vomit immediately after eating may have a gastric motility problem -
ranitidine may help with
this.
Occasionally vomiting is caused by
constipation,
particularly if your cat vomits before, during or immediately after using the litter tray.
If you are giving your cat sub-Q fluids and s/he regularly vomits after
fluids, this may because of the
type of fluid
used.
Vomiting does not just include food -
the classic symptom of excess stomach acid is to vomit clear or white foam.
This is often one of the first signs that people notice when their cat is
developing CKD.
Vomiting Water
Sometimes
CKD cats drink a lot on water in one go, them vomit all or most of it up
shortly afterwards. This may be a sign of excess stomach acid. It is possible
that the cat has an urge to drink before vomiting so as to dilute the
stomach acid.
Lip Licking
This can be
a sign of nausea and excess stomach acid. It may also be a sign of
dehydration. Less commonly, it can be a sign of
anaemia. In rare cases it may be caused
by longer term (over three months) use of
Cats who
grind their teeth may have excess stomach acid.
Dental problems
are
another possible cause. It may also be a sign of
dehydration. Very occasionally, this might be a sign of
"rubber
jaw", caused by a condition related to CKD called
secondary hyperparathyroidism.
Cats
commonly eat grass in order to help themselves vomit. They often do this
if they want to bring up a hair ball, and this is
sometimes also the reason why CKD cats eat grass. However, CKD cats do
tend to feel nauseous generally, because of the disease rather than
because of hair balls, and if
you feel nauseous, you may feel a little better if you can actually vomit. Therefore
CKD cats who feel nauseous may eat grass in order to make themselves
vomit. It is normally fine to allow your CKD cat to eat grass, as long as
it has not been treated with pesticides.
This can be
a sign of nausea and excess stomach acid. Occasionally it is a sign of
dehydration.
Playing with Water
Some cats
like to play with their water bowls from an early age, but some CKD cats
develop a bit of an obsession with water, and may play with their water
bowl or paw at the water. You may see other new behaviours, such as
drinking from showers or gutters, or hanging around sinks and begging for
fresh running water from the tap. All these types of behaviour may
indicate excess stomach acid. Other possible causes include
dehydration or
diabetes.
Sniffing or Licking or Looking at Food, then
Walking Away
The cat may
approach the food bowl and sniff or lick the food, then walk away. This is a
pretty classic sign of excess stomach acid, but it may also indicate
mouth ulcers.
Pawing at the Mouth
The most
common reason for this is
dental problems,
but occasionally it is a sign of excess stomach acid.
Increased
Drinking
Increased
drinking is common in CKD cats because they usually have problems
maintaining hydration. However, it can also be a symptom of excess stomach acid. In some
cases it may indicate diabetes.
Licking Gravy Only
The cat may
lick the gravy only and leave any solid food behind. However, this may not
indicate excess stomach acid in all cats, only if it is a new behaviour - my cats
do this all the time and they are healthy, they just prefer pâté-type
foods. Another possible cause is
dental problems.
Sitting Hunched Up
Since cats
with excess stomach acid have sore tummies, they may sit in a hunched up,
uncomfortable position. In the worst case, this may indicate
crashing, but only
if you also see the symptoms described there.
The best treatment for vomiting, nausea and loss of appetite depends upon
the cause of the problem. This page focuses on treatments for these
problems caused by toxins including excess stomach acid. You can check the
Although it is not possible to test for toxins,
particularly excess stomach acid, if your cat is showing any of the
symptoms described above (e.g.
vomiting white foam),
it is usually worth treating for it, and seeing
if your cat feels better. Here is a
possible staged treatment plan for you to discuss with your vet:
Firstly, try these simple natural treatments - for some cats,
especially those in early stage CKD, these are the only treatments they
need:
If these treatments don't seem to be helping after a couple of days, move onto the
histamine H2 antagonists (acid blockers), which are a group of
medications commonly used to control excess stomach acid. These help the
vast majority of cats. You can use these in conjunction with the natural
treatments.
If your cat is still struggling, consider anti-nausea medications. These
medications are usually very effective for nausea and vomiting, and may be
the best choice for cats with additional issues, such as gastric mobility, or cats
with concurrent pancreatitis or IBD. They can usually be used in
conjunction with the medications outlined above:
It is usually safe to use more than one of these treatments at the same time, e.g.
slippery elm bark and famotidine, but check with your vet first. Don't use
Pepto-Bismol
or
antacids such as Tums or Mylanta
The beauty of these treatments is that they need little effort, are not
particularly invasive and require very little outlay, yet for some cats they are
extremely effective. I therefore recommend trying them to see if they
help. If they are going to help, you would normally see a difference (e.g.
reduced vomiting) within a couple of days.
Normally a cat
eats with the mouth lower than the stomach, but in CKD cats this can cause
stomach acid to enter the oesophagus and trigger acid reflux. Keeping the
cat's food and water bowls higher than the stomach can help minimise this
problem and may encourage your cat to eat and drink more.
Standing bowls on an upside-down flower pot can often create the correct
height for your cat and provide a sturdy base: choose a flower pot of the
appropriate height for your cat. Some pet stores also sell food dishes on
legs, which are approximately 6 inches (15cm) high.
Classy Cat
Dishes sells raised stoneware
bowls for about US$25. I have some of these, and my cats love them.
My cats do not have CKD, but I have noticed they eat more if I feed them
from these bowls.
Drs Foster & Smith sell a cast iron raised food bowl stand from US$17.99.
They also sell some other raised bowls.
Feeding Before Bedtime
You may find that your cat has more stomach upsets at night
which cause vomiting during the night or first thing in the morning. This
happens because if a cat goes a long time without eating, the excess
stomach acid has more time to attack the stomach lining.
In addition to using the other treatments mentioned here, try to
ensure that your cat eats before bedtime in order to prevent this -
keeping food constantly in the stomach means the acids are more likely to
attack the food rather than the stomach lining. It may also be worth
setting up an automated feeder on a timer with food in it to keep your cat supplied with food
throughout the night. There are links to such feeders
here.
Slippery Elm Bark
If you wish to pursue natural methods of controlling stomach acid and the
accompanying vomiting, nausea and loss of appetite, a herbal remedy
called slippery elm
bark (SEB) is often very effective. It soothes the digestive tract, so it can also help with
both constipation
and
diarrhoea.
The
Holistic Treatments page has more detailed information on SEB.
This is a group of medications which can be most effective in controlling
excess stomach acid, which can greatly reduce vomiting and nausea and increase appetite.
Most of these medications are thought of as antacids, although in
fact technically speaking they are histamine H2 antagonists that block the
production of stomach acid rather than neutralise it. Because they are
long-acting, they are generally a good choice for treating stomach acid
problems. In
Current concepts for the management of chronic renal
failure in the dog and cat - early diagnosis and supportive care
(2005) Presentation to the 30th World Congress of the World Small
Animal Veterinary Association, Dr Sherry Sanderson mentions that it is
generally recommended to use such treatments once creatinine is over 3
(USA) or 265
(international).
Although these medications can be purchased
over the counter, please do NOT give them without first discussing them
with your vet, particularly if your cat has advanced CKD, because they are
excreted by the kidneys so may not be appropriate. Avoiding Adverse Drug Reactions (2001), a paper presented by Lauren
Trepanier to the World Small Animal Veterinary Association World
Congress 2001, mentions that it is wise to reduce the dose of these
medications in CKD cats (scroll to the end).
Once you start giving these medications, it is usually better to
continue giving them regularly even if your cat appears better,
so the excess stomach acid cannot start building up again.
The active ingredient in Pepcid AC is famotidine USP,
and Pepcid AC (Regular Strength) contains 10mg. Famotidine may be sold under a
different name in your country (e.g. Amfamox, Famox or Pepcidine in New Zealand and
Australia).
General
Medical shows which trade names famotidine is known by in
various
countries.
If you opt for the brand name, there are quite a few Pepcid products
available these days so make sure you buy the correct one. You need Pepcid
AC 10mg but not the chewable type, and not Pepcid Complete, both of which have some ingredients which make them unsuitable for
CKD
cats. There is also a new version called Pepcid Maximum Strength, which is
the same as Pepcid AC except that it contains twice as much famotidine, so
be very sure you have the correct strength (10mg tablets).
Unfortunately, Pepcid AC has been discontinued in the UK,
having been replaced by PepcidTwo.
PepcidTwo contains magnesium and calcium in addition to famotidine, so it
is not suitable for CKD cats. Famotidine does exist in generic form and is
available from chemists, but only in 20mg size, which could be difficult
to cut; plus it requires a prescription from your vet. If you really want
to use famotidine, it is sometimes available from
Amazon UK in the 10mg strength at prices ranging from £5-65
(search for Pepcid AC or famotidine).
You can also obtain it in compounded cat-sized form from
The Specials Laboratory
- 90 2.5mg capsules cost
£93.79 plus VAT and shipping costs of around £12.50. They also sell
100ml of
famotidine 2.5mg per ml for £91.89, with a 90 day expiry from manufacture.
If you don't want to pay those prices, I would
consider using
ranitidine instead.
Famotidine Dosages
Famotidine is excreted by the kidneys, and cats with CKD cannot process it
as efficiently as healthy cats, so it may
accumulate in the cat's body and cause problems.
The US Food & Drug Administration has
information about the need to reduce the normal dose in (human) CKD
patients.
Avoiding Adverse Drug Reactions (2001), a paper presented by Lauren
Trepanier to the World Small Animal Veterinary Association World
Congress 2001, mentions that it is wise to do the same with CKD cats
(scroll to the end).
Below are suggestions for famotidine dosages for CKD cats, but be guided by
your vet. You should only use famotidine with your
vet's approval. Do not start with the maximum dose, it could be risky.
Starting dose:
2.5 mg once every other day (i.e. quarter of a 10mg tablet once every two
days e.g. on Mon, Wed, Fri)
Intermediate dose (if starting
dose does not seem to be helping):
2.5mg once a day (i.e. quarter of a 10mg tablet
once a day)
Maximum dose:
2.5mg twice a day (i.e. quarter
of a 10mg tablet twice a day, 5mg a day in total)
If you are only giving famotidine once a day, I would recommend doing so at bedtime because
this seems to help cats who vomit at night or first thing in the morning. Famotidine tastes quite bitter and can make cats foam at the mouth, so you may find it easier to give it in a
gelatine
capsule (gelcap).
It usually takes effect
pretty quickly, within a couple of days for most cats.
Famotidine Oral Suspension
If your cat is hard to pill, famotidine is also available as an injectible
or an oral suspension (liquid).
Thriving Pets sells a 10mg/ml oral
suspension (liquid) version of famotidine in a 30ml size, so if you want
to give the usual famotidine dose of 2.5mg, you would give 0.25ml. This
product has a short shelf life, so you should not order more than 14 days
worth at a time (including delivery). Like the pills, this form of
famotidine is also very bitter, so if you don't want to give your cat
bitter oral medications,
consider using injectible famotidine instead. If you
enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
Famotidine Injectible
There are two types of famotidine injectible. There is a 10mg/ml
strength without preservative, which is available in 2ml vials. Because it
contains no preservatives, this has a short shelf life (it is intended for
single use in humans). There is also a 10mg/ml strength available in
a 20ml
size vial. This contains a preservative and can be re-used, though it should be
kept in the fridge.
You can use the injectible either by injecting it directly into your cat,
or if your cat is on sub-Qs, by adding it to the injection port of your IV
line. It is safe to take it out about 30 minutes before using it so it can
warm up a little before use.
Thriving Pets sells the 10mg/ml
injectible form of famotidine in a 20ml size, so if you want to give the
usual famotidine dose of 2.5mg, you would give 0.25ml. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
Famotidine Side Effects and Interactions
The most common side effects in humans are constipation or diarrhoea.
Some cats, particularly those with high bloodwork
(creatinine over 5 USA, 450 international),
do not do well on famotidine, perhaps because their kidneys cannot excrete
it efficiently as described above. These cats may in fact exhibit increased vomiting
and appetite loss when given it - this happened to our
Thomas.
Drugs
mentions how an overdose may cause vomiting. If your cat's vomiting
and appetite loss do not improve after two days of using famotidine,
ask your vet about switching to
ranitidine.
Famotidine may adversely affect cats with existing heart rhythm
problems. In such cases you may wish to ask your vet about using
ranitidine instead.
Medicine Net mentions that famotidine may cause
anaemia in humans.
Web MD
reports that human CKD patients on famotidine may exhibit abnormal levels
of drowsiness.
Famotidine (Pepcid AC) can interfere with antibiotics in the
cephalosporin family such as
Convenia, so you should separate the two treatments by two hours.
I used to recommend giving famotidine at least two hours apart from
sucralfate (Carafate
or Antepsin) or
metoclopramide (Reglan), because, according to
Plumb's Veterinary Drug Handbook, these other medications could bind
with the famotidine and thereby reduce its effectiveness. However, the
most recent edition of Plumb's does not mention this requirement, so it
appears that you do not need to separate famotidine from these other
medications after all.
RX Med states that "concomitant use of
aluminum hydroxide/magnesium hydroxide at commonly used doses, does not
influence the pharmacodynamics or bioavailability of Pepcid AC." Plumb's does still recommend separating famotidine from
phosphorus
binders and
ACE inhibitors. I would try to err on the side of caution and still separate
famotidine from phosphorus binders and ACE inhibitors if you can, but if
this is difficult for you, e.g. because of work commitments, just do the
best you can.
Veterinary Partner has more
information on famotidine, and mentions how it may adversely affect cats
with heart rhythm problems.
Pet Place has more information
about famotidine (no need to register to read the article, just click on
Close at the bottom of the pop-up).
The Merck Manual has more information
about famotidine and its possible side effects in humans.
Ranitidine (Zantac 75)
Another popular over the counter histamine H2 antagonist is ranitidine (trade name is Zantac 75),
which
works in a similar way to famotidine. Some people prefer to use
ranitidine, especially if their cat has experienced increased vomiting with
famotidine, as happens with a small number of cats (usually those with
creatinine over 5 USA, 450 international).
One reason why people may decide not to use ranitidine is that it usually
has to be given twice a day, whereas famotidine is usually only given once
every other day, or occasionally once a day.
The usual dose is 0.25 to 1.00 mg per pound (0.5 - 2.00 mg per kg) every
8-12 hours, though most people find twice a day is fine.
You therefore would give a 10lb (4.5kg) cat 2.5 - 10 mg twice a day.
The standard size pill is 75mg, so for a
10 lb (4.5kg) cat who is getting the higher dose, it is usually easiest
simply to give an eighth of a tablet twice a day (i.e. 9.375 mg, or a
little under 10 mg).
Some people give up to twice this amount, but as with famotidine,
I suggest starting low and increasing the dose if necessary since
ranitidine
is also excreted by the kidneys. Be guided by your vet.
Ranitidine tastes quite bitter and can make cats foam at the mouth, so you may find it easier to give it in a
gelatine
capsule (gelcap).
Many people prefer to give the second dose of the day at bedtime because this seems to help cats who
vomit at night or first thing in the morning. It usually takes effect
pretty quickly, within a couple of days.
The main problem with ranitidine is dividing the tablets up into cat-sized
dosages. If you find it hard to cut the pill into eight, you could try
dissolving it in water and giving an eighth of the resulting mixture via
syringe.
Ranitidine Oral Suspension
There is also a liquid (syrup) form of ranitidine, but this is
peppermint flavoured, so not many cats would like it, plus you need a
prescription for it. However, I understand you can obtain it in a beef
flavoured compounded suspension from
Thriving Pets. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
Ranitidine Injectible
There is also a prescription only injectible form of ranitidine made by
Bedford Laboratories, obtainable from
most US pharmacies (they may need to order it for you, and it seems to go
out of stock quite regularly in recent times).
Injectible ranitidine comes in a 25mg/ml strength, usually in a 6ml vial.
You can either inject this directly into your cat, or if your cat is
on sub-Qs, add it to the injection port of your IV line. A possible
dose is 0.3ml twice a day, but ask your vet. Injectible ranitidine usually
needs to be refrigerated but it is safe to take it out about 30 minutes
before using it so it can warm up a little before use.
Thriving Pets sells injectible ranitidine. If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
Ranitidine Side Effects and Interactions
Ranitidine may cause vomiting and diarrhoea in some cats. Like famotidine,
it should be used in caution in cats with heart murmurs.
It is also advisable to separate ranitidine from
ACE inhibitors
such as Fortekor, but if this is difficult for you, e.g. because of work
commitments, just do the best you can.
Pet Place has more information about Zantac
(no need to register to read the article, just click on Close at the
bottom of the pop-up).
Cimetidine (Tagamet)
You may be offered another drug in this family called cimetidine.
Cimetidine has many more drug interactions than either famotidine
or ranitidine, including with
amlodipine (a calcium channel blocker used to treat
heart disease or high blood pressure), and
diazepam (Valium), which is
sometimes used as an appetite stimulant. It also has the most marked
rebound effect (a temporary increase in stomach acid) if it is stopped.
I would therefore suggest using famotidine or ranitidine instead.
Top ten potential drug interactions on dogs and cats
(2008) Trepanier LA Presentation to the World Small Animal Veterinary
Association World Congress recommends using famotidine or ranitidine
rather than cimetidine.
Pet Place has information about
cimetidine (no need to register to read the article, just click on Close at
the bottom of the pop-up).
If the natural treatments above don't work, and your cat does not respond
too well to acid blockers such as famotidine, or perhaps shows some
improvement but still vomits fairly frequently, you may need to
consider trying one of these other medications. These medications treat
nausea and/or vomiting but they all work in different ways, so discuss
with your vet whether one of them might be suitable for your cat.
Pharmacologic control of vomiting
(2009) Tams TR CVC in Kansas City Proceedings discusses the use of these medications and others in
cats.
Ondansetron (Zofran)
This drug is commonly used to control vomiting in cats with pancreatitis
or cancer. I first heard of somebody using ondansetron for a CKD cat in
2002, but it has not been used routinely in CKD cats until recently,
mainly because it was extremely expensive. Since the generic version became available in the USA, however, it is becoming quite
popular for use in CKD cats, not least because it is very effective. Its
trade names include Zofran in the USA, Setronon in Europe and Emeset in the
UK.
Ondansetron works in a different way to metoclopramide below (it selectively inhibits serotonin 5HT3 receptors), so it does not
lower the seizure threshold as metoclopramide does.
Some people use another drug in this family, dolasetron (Anzemet), which
only needs to be given once a day, but dolasetron seems to be more commonly used at this time for cats with pancreatitis.
Pharmacologic control of vomiting
(2009) Tams TR CVC in Kansas City Proceedings has some information about dolasetron.
Ondansetron Dosages
Ondansetron comes in 4mg pills, and a commonly used dose is 1 mg each day,
so one pill contains four doses. This works well for many CKD cats;
however,
Pet Place mentions
that the usual dose for cats is 0.11mg per pound bodyweight every 8-12
hours, so the usual dose may not be sufficient for some cats, particularly
those with pancreatitis. If you find this is the case, speak to your vet
about increasing the dose as outlined by Pet Place.
The pills are tiny, so can be hard to cut into quarters.
You can be charged as much as US$6 for a single pill, so you need to shop
around, because it is possible to buy the generic pills much more cheaply.
Health Warehouse sells 30 ondansetron 4mg
tablets for US$22 including shipping.
Thriving Pets sells ondansetron for US$1
per 4mg pill, or 80 cents each if you buy thirty. A prescription is required.
If you enter the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
£7.49 for 30 plus shipping (total cost is a little under
£10). A prescription is required.
Ondansetron Injectible
There is also an injectible form of ondansetron.
Thriving Pets
sells 10 vials (4mg/2ml) for US$25. If you enter
the word "tanya" (without the ") in the
promotional code box, you will receive a 10% discount on orders over
US$55. Shipping is free for orders over US$55 after the discount.
Unfortunately injectible ondansetron stings a lot, but it may be a good
choice for a cat who is struggling to keep anything down, and it does work
quickly - you should see results within a couple of hours.
Ondansetron Interactions and Side Effects
Possible side effects include constipation, low blood pressure and sleepiness. Humans have reported bad
headaches.
Drugs has more information about possible
side effects.
Ondansetron may also cause heart arrhythmias. In September 2011
The US Food & Drug Administration
reported that "Ondansetron may increase the risk of developing abnormal
changes in the electrical activity of the heart, which can result in a
potentially fatal abnormal heart rhythm."
Maropitant (Cerenia)
is a relatively new treatment from Pfizer. The injectable form is approved for the
treatment of vomiting and nausea in cats (and dogs) in the USA. In some parts of Europe
maropitant is approved for travel sickness in
cats.
Treatment for visceral pain with the new NNK-1
receptor antagonist maropitant in cats
(2011) Boscan P, Monnet E, Twedt D & Nyiom S, found that maropitant
may also be an effective painkiller.
It only needs to be given once a day and does appear to be quite effective
for some cats, usually taking effect within an hour. It works by blocking
the stimulation of the part of the brain that instigates vomiting. I am
concerned that this might mean that the cat may still feel nausea (and therefore may
not want to eat), but will not vomit. However, some people do find
maropitant works better for their cats than ondansetron, so if you are not
finding ondansetron to be as effective as you hoped, I would try
maropitant instead.
Maropitant is available in either injectible or pill form. Both the
injectible and the pill form are intended to prevent vomiting, but the
injectible form is also designed to treat acute vomiting. The injectible
form seems to sting some cats, and the oral form seems to taste horrible.
For the injectible form a commonly used dose appears to be 0.5 to 1mg per kg (2.2lbs) of body weight.
A 10 lb (4.5 kg) cat would therefore receive 2.25 - 4.5mg.
The pills should not be given in
Pill
Pockets or mixed with food as this may stop them being properly
absorbed in the cat's body.
The manufacturer recommends that maropitant should only be given short
term to dogs, for a maximum of five days at a time. Some people have used
it in their cats for a few days, taken a break, then used it again.
Plumb's Veterinary Drug Handbook mentions that the medication should be
stopped for at least 48 hours in these circumstances. In the above study, it was used for
fifteen days without a break in cats with no apparent problems. I know that after
learning about this study, some people have given their cats maropitant for
longer than five days and not seen any adverse effects. Be guided by your
vet on the best approach for your cat.
Maropitant Side Effects and Interactions
Possible side effects include vomiting, lethargy, diarrhoea, twitching and
drooling. Maropitant should not be used if there is any
gastro-intestinal obstruction, and should be used with caution if liver or
heart problems are present.
The European Medicines Agency says
(clause 4.8 on page 9) that "Cerenia should not be used concomitantly
with Ca-channel antagonists as maropitant has affinity to Ca-channels."
The University of Zürich Institute for Veterinary
Pharmacology and Toxicology also
mentions this (in German). In principle this means that maropitant should not be used with calcium channel
blockers such as
amlodipine (Norvasc or Istin, commonly used to treat high blood
pressure in CKD cats).
'Concomitantly' has a rather vague medical
meaning in that it means during the same time period, but in this context
I don't know exactly what time period the EMA is referring to, i.e. do
they mean at the same time or on the same day? Both of these medications
tend to be given once daily, so they have a relatively long effect. I
suspect that giving them both on the same day but 12 hours apart (i.e. one
in the morning and one in the evening) would probably be acceptable, but
check with your vet.
Pfizer product information sheet (tablets)
mentions that maropitant should only be given for five days. It also
states that maropitant may interact with phenobarbital, used to control
epilepsy, and
NSAIDs.
The Veterinary Teaching Hospital at Colorado State University is
seeking volunteers for a study into the use of maropitant
for the treatment of nausea and vomiting in cats with
CKD. Cats that have been diagnosed with stable chronic
kidney disease and who have a “picky” appetite, nausea or vomiting, are
potentially eligible for entry into this study. Cats with other illnesses
may not be eligible.
The cat will
be given a
complimentary physical exam and chemistry panel at the beginning of the
study. The study involves giving cats either maropitant or a placebo daily for two weeks. After two weeks,
the cat will
receive a second complimentary physical exam and complimentary blood tests
(blood chemistry
panel). During the study, the owner will be asked to fill out a daily diary
of the cat’s behavior and other details. Owners receive complimentary veterinary visits and chemistry
tests; a $100 stipend is offered to the participating veterinarian per cat
enrolled to cover these costs.
If you wish to
participate, please contact Dr Jessica Quimby on
970-297-5000 or at
jquimby@colostate.edu.
Metoclopramide (Reglan)
Metoclopramide is a prescription only medication which works by regulating stomach
contractions. This means it can help with nausea caused by a lack of
motility in the stomach. Since metoclopramide can cross the blood/brain barrier,
it also acts on the brain to control feelings of nausea.
Pet Place has some information about
gastric motility problems in cats (you don't need to register to read the
article, just click on Close at the bottom of the pop-up window).
Metoclopramide Dosages
Metoclopramide comes in
10 and 5mg tablets or a liquid. Injectable metoclopramide is also
available as 5mg/ml in 2 ml or 10 ml vials. It must be
given 20-30 minutes before eating.
A typical dose would be 0.1 to 0.2 mg per pound (0.2 to 0.5 mg per kg)
every six to eight hours, so a 10lb (4.5kg) cat would get 1 mg to 2 mg at
a time, but be guided by your vet.
Metoclopramide Side Effects and Interactions
Metoclopramide may have various side effects,
including constipation, hyperactivity and agitation or drowsiness; very
occasionally, twitching may be seen.
Metoclopramide also lowers the seizure
threshold, so should not be given to cats prone to
seizures.
Drugs mentions that it may increase the risk of bronchospasm in asthmatics, and
intravenous metoclopramide may worsen hypertension (high blood pressure).
On 26 February 2009, the
US Food and Drug Administration warned
against the "chronic use of these products [metoclopramide-containing
drugs] to treat gastrointestinal disorders." This is because products
containing metoclopramide have been linked to a condition called tardive
dyskinesia, i.e. involuntary and repetitive movements of the body, which
may continue even after the treatment is stopped. One such movement
mentioned by the FDA is
lipsmacking (although it should be noted that lipsmacking in
CKD cats
is normally caused by excess stomach acid or nausea,
anaemia
or
dehydration).
The FDA therefore recommends that products containing metoclopramide
should not be used for longer than three months. Obviously this warning
applies to humans, but I would discuss the warning with your vet if
you want to use metoclopramide for longer than three months.
I used to recommend giving metoclopramide at least two hours apart from
famotidine (Pepcid AC) or
ranitidine (Zantac 75)
because, according to
Plumb's Veterinary Drug Handbook, the metoclopramide could bind with
these other medications and reduce their effectiveness. However, the most
recent edition of Plumb's does not mention this interaction, so it appears
that you do not need to separate metoclopramide from these other
medications after all.
Pet Place
also has some information (no need to register to read the article, just
click on Close at the bottom of the pop-up).
Drs Foster and Smith
have some information about possible side effects. They also
mention that metoclopramide is similar to PABA, the sunscreen component,
so people who are allergic to PABA should not touch metoclopramide.
Please do not use Pepto-Bismol. It contains a type of salicylate,
similar to what is found in aspirin, and cats are not able to metabolise
this easily, so it may be fatal even in small doses.
Some vets recommend the use of antacids, such as Tums or Mylanta. Some
products in this family do actually work well in CKD cats as
phosphorus binders,
but they are not usually strong enough to help control excess stomach acid, plus
using products containing
magnesium is not usually recommended for CKD
cats, who tend to have high levels of magnesium generally.
TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE
EXTREMELY DANGEROUS.
I have
tried very hard to ensure that the information provided in this website is
accurate, but I am NOT a vet, just an ordinary person who has lived
through CKD with three cats. This website is for educational purposes
only, and is not intended to be used to diagnose or treat any cat. Before
trying any of the treatments described herein, you MUST consult a
qualified veterinarian and obtain professional advice on the correct
regimen for your cat and his or her particular requirements; and you
should only use any treatments described here with the full knowledge and
approval of your vet. No responsibility can be accepted.
If your cat
appears to be in pain or distress, do not waste time on the internet,
contact your vet immediately.
This site was
created using Microsoft software, and therefore it is best viewed in
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is on making the information available. When I get time, I'll try to
improve how it displays in other browsers.
You may print
out one copy of each section of this site for your own information and/or
one copy to give to your vet, but this site may not otherwise be
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Contact Me
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This site is a labour of love on my part. Please do not steal from me by taking credit for my work.
If you wish to
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