TANYA'S

COMPREHENSIVE GUIDE TO

FELINE CHRONIC KIDNEY DISEASE

 

 

 

PANCREATITIS

 

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Triaditis


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Home > Related Diseases > Pancreatitis

 


Overview


  • Pancreatitis is inflammation of the pancreas, a gland which assists with the digestive process and controls the hormones which regulate blood sugar.

  • CKD cats sometimes also have pancreatitis. To confuse matters, pancreatitis may sometimes cause elevated creatinine levels.

  • If your cat has relatively low creatinine levels (below 2.25 mg/dl or 200 µmol/L), yet seems lethargic and far more ill than that mild level of kidney disease would suggest, ask your vet to consider pancreatitis.


What is Pancreatitis?


 

The pancreas is a gland located under the stomach with two main roles:

  • endocrine (hormonal): it controls the hormones (insulin and glucagon) which regulate blood sugar levels.

  • exocrine: it assists with the digestive process by producing digestive enzymes.

In cases of feline pancreatitis, it is usually the exocrine function which is affected. The pancreas becomes inflamed, and the enzymes which it would normally release into the intestines are instead released into the pancreas itself, causing pain and further inflammation. The liver may also be affected (see below).

 

If the part of the pancreas responsible for endocrine function also becomes damaged, diabetes may develop.

 

During pancreatitis, toxins move throughout the body, and in the worst cases, respiratory failure or brain damage may result, though fortunately such severe effects are uncommon.

 

Pancreatitis can be either acute or chronic. Acute cases often resolve completely, whereas cats with chronic pancreatitis may have flare ups at intervals.

 

Mar Vista Vet has an overview of feline pancreatitis.

 


Feline Triaditis


 

Feline triaditis is the term used for a cat who is suffering from the triple whammy of inflammation of:

Which tends to come first is a matter of some debate. One reason triaditis may occur in cats is because, unlike other species, which have separate bile and pancreatic ducts, the feline pancreatic duct often merges with the bile duct before reaching the intestine. Therefore inflammation in any one of these three body parts can easily spread to all three.

 

Chronic diarrhoea in cats Gunn-Moore DA Purina Presentation explains more about triaditis (page 15).

 


Causes of Pancreatitis


 

Often the cause is never discovered (Chronic diarrhoea in cats Gunn-Moore DA Purina Presentation says "While there are many possible causes of pancreatitis in cats, over 90% are idiopathic"), but it may be linked to an autoimmune disease, inflammation or an infection. Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says (Dr Twedt, referring to research from 2011) "we identified bacteria in the pancreas of about 40% of cats with moderate to severe chronic or acute pancreatitis."

 

The following may also be factors:

  • cats who suffer trauma, such as from an accident, appear to be at risk.

  • cats with diabetes or IBD may be at increased risk.

  • cats with CKD who have uraemia may be at increased risk.

  • many cats with hepatic lipidosis go on to develop pancreatitis, and the prognosis is more guarded for such cats.


Frequency


 

Pancreatitis appears to be more prevalent in cats than was previously thought.

 

Prevalence and histopathologic characteristics of pancreatitis in cats (2007) De Cock HEV, Forman MA, Farver TB & Marks SL Veterinary Pathology 44 pp39-49 examined deceased cats and found that chronic pancreatitis "is common in cats, with an overall study prevalence of 67%, including 45% of apparently healthy cats." They also found that chronic pancreatitis is more likely in older cats.

 

If your cat exhibits the symptoms described below, ask your vet to rule out pancreatitis.

 


Symptoms


 

Unfortunately pancreatitis does not have a clear-cut set of symptoms unique to the disease, though the symptoms you do see may vary, depending upon whether the pancreatitis is acute or chronic, or an acute flare up in a cat with chronic pancreatitis.

 

Idexx Laboratories refer to cats with pancreatitis as ADR cats - cats who "ain't doing right" (which their UK site describes as "under the weather"). With both acute and chronic pancreatitis, lethargy and loss of appetite are extremely common: in one study, lethargy was seen in 100% of cats with pancreatitis and loss of appetite in 97%. Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says "Cats with pancreatitis present like cats always present - with anorexia, vomiting, and lethargy." One of the other participants said he usually sees reduced appetite, and also weight loss. In cats with chronic pancreatitis, this may be cyclical.

 

Cats with acute pancreatitis may develop fluid build up, such as ascites (fluid in the abdomen. Chronic diarrhoea in cats Gunn-Moore DA Purina Presentation states "Some will show dyspnoea associated with pleural fluid and/or pulmonary oedema (resulting from pleural and/or pulmonary inflammation secondary to circulating inflammatory mediators)."

 

Whether acute or chronic, some cats seem to have abdominal pain and some do not.

 

Can we diagnose feline pancreatitis and do we need to? (2008) Mansfield C Presentation to the 33rd World Small Animal Veterinary Association World Congress has a table of symptoms which may be seen.

 

As you can see, many of the sympoms of pancreatitis are very similar to those seen in CKD cats. From what I have seen on Tanya's CKD Support Group, many cats who have relatively low creatinine levels (below 2.25 mg/dl or 200 µmol/L) but who are acting a lot sicker than you would expect a cat with such low numbers to act, are actually suffering from pancreatitis, either in addition to CKD or sometimes without CKD being present. Therefore if your CKD catis off colour with no obvious cause shown in standard bloodwork, consider pancreatitis.

 


Diagnosis


 

Diagnosing pancreatitis in cats is unfortunately not simple. A biopsy is the most definitive way to do so, but it is invasive, and therefore most vets no longer perform biopsies for suspected pancreatitis.

 

Instead, a combination of other diagnostic methods are used. Canine and feline pancreatic lipase immunoreactivity (2012) Xenoulis PG & Steiner JM Veterinary Clinical Pathology 41(3) pp312-24.states "As there is currently no gold standard for antemortem diagnosis of pancreatitis in dogs and cats, the combination of a complete history and physical examination, measurement of pancreatic lipase immunoreactivity, and ultrasonographic examination of the pancreas is the best approach for an accurate noninvasive diagnosis of pancreatitis.”

 

Diagnosing and managing feline pancreatitis, a roundtable discussion (2008) Robertson J, Forman M, Steiner J, Twedt D & Williams D IDEXX Laboratories has a protocol for diagnosing pancreatitis in cats.

Ultrasound


Ultrasound may be used initially to see if there are any changes in the pancreas. If so, the vet may order further tests. However, it can be hard to detect the pancreas on ultrasound, and ultrasound may not detect pancreatitis in every cat with the disease, even when performed by a skilled operator. Feline pancreatitis (2012) Reichle JK & Felumlee AE NAVC Clinician's Brief Jun 2012 discusses the use of ultrasound in diagnosing pancreatitis but states "the sensitivity of ultrasonography for feline pancreatitis is low and has been reported as only 10% to 35% when performed by a board -certified ultrasonographer."

 

Agreement of serum feline pancreas-specific lipase and colorimetric lipase assays with pancreatic ultrasonographic findings in cats with suspicion of pancreatitis: 161 cases (2008-2012) (2014) Oppliger S, Hartnack S, Reusch CE & Kook PH Journal of the American Veterinary Medical Association 244(9) pp1060-5 states "Agreement between pancreatic ultrasonography and lipase assay results was only fair. It remains unknown whether lipase results or pancreatic ultrasonography constitutes the more accurate test for diagnosing pancreatitis; therefore, results of both tests need to be interpreted with caution."

 

An ultrasound may not show pancreatitis even in cats who are known to have it. Feline acute pancreatitis: current concepts in diagnosis and therapy (2015) Armstrong PJ & Crain S Today's Veterinary Practice 5(1) pp22-32 states "some cats with biopsy-confirmed acute pancreatitis have no detectable sonographic abnormalities." It  does add "However, the sensitivity of ultrasonography increases with increasing severity of pancreatitis" and says "Abnormal sonographic findings are highly specific for pancreatitis—a cat with compatible clinical signs and visible changes in the pancreas is very likely to be correctly diagnosed with pancreatitis."

 


Blood Chemistry


Special blood test for pancreatitis in cats are available (see below) but your vet may initially suspect pancreatitis from your cat's symptoms and certain results in general bloodwork (known as blood chemistry).

 

Low Calcium Levels (Hypocalcaemia)


Up to 50% of cats with pancreatitis have low calcium levels (hypocalcaemia). Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says "if a cat is hypocalcemic and has an inflammatory leukogram, I think about acute pancreatitis. I usually make a clinical diagnosis with imaging (ultrasound) and feline  pancreatic lipase immunoreactivity (fPLI) test results, along with ruling out other etiologies."

 

Serum ionised calcium as a prognostic risk factor in the clinical course of pancreatitis in cats (2015) Dias C & Carreira LM Journal of Feline Medicine & Surgery 17(12) pp984-90 found that 58.3% of the cats in the study had hypocalcaemia, and concludes that ionised calcium "may be used as a prognostic risk factor for predicting the clinical course of the disease, with values < 1 mmol/l corresponding to a poor prognosis."

 

Other Blood Chemistry Findings


  • BUN and creatinine may be elevated because of pre-renal azotaemia.

  • Potassium may be low.

  • White blood cells are usually high.

  • ALT and AST, both liver enzymes, are often elevated.

  • The cat may be anaemic.

Amylase and Lipase


In dogs with pancreatitis, amylase and lipase (pancreatic enzymes) are often elevated, but unfortunately these will not necessarily be elevated in cats with pancreatitis, so normal levels do not rule out pancreatitis. Pancreatitis in cats (2004) Williams D Presentation to the World Small Animal Veterinary Association World Congress says "Serum lipase and amylase activities have been shown to be of no clinical usefulness for the diagnosis of pancreatitis in cats. Current evidence suggests that when values of these enzymes in feline serum are increased, the underlying disease is not present in the pancreas. Many such cats have chronic small intestinal disease and/or gastritis."

 

Testing amylase and lipase is therefore of no benefit in cats. Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says "We do not include these on our panels anymore."

 


Specialised Tests


 

There are a number of specialised tests available and your vet will probably use one of these.

 

Diagnosing feline pancreatitis (2012) Forman MA has a table comparing the accuracy of the various tests available.

 

Spec fPL Test


This test was developed by IDEXX Laboratories in conjunction with Texas A&M University (TAMU) and measures pancreatic lipase immunoreactivity (PLI). This test superseded another test also developed by TAMU called the fPLI test (see below). The Spec fPL test appears to be slightly less accurate than the original PLI test, but the test is available from IDEXX laboratories around the world (the PLI test sample had to be sent to Texas A&M University), so it is a much more widely available test.

 

Results are usually available quickly, within a day. When a member of Tanya's CKD Support Group had it done in 2015, it cost US$160, but price will vary depending upon where you live.

 

In theory cats should be fasted for this test, but it is not essential (results might vary by around 10% if the cat is not fasted, but this is unlikely to make much difference unless your cat has a very borderline result).

 

Results are interpreted as follows:

 

Level Interpretation
Below 3.5

Probably does not have pancreatitis. Consider other causes.

Between 3.5 and 5.3

May have pancreatitis. Re-run the test in two weeks.

Above 5.3 Probably has pancreatitis.

 

IDEXX has some brief information about the test.

IDEXX compares the Spec fPL test to the fPLI test).

 

Limitations of the Spec fPL Test


Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says "Veterinarians sometimes get a positive fPLI result and stop right there, assuming that the positive test definitively means pancreatitis ... which is a big mistake."

 

This is because the test is not 100% accurate in every case, particularly in less severe cases. IDEXX itself states "Sensitivity [ability to detect pancreatitis] of the fPLI test was 100% in moderate to severe cases of pancreatitis and 54% in mild cases, with an overall sensitivity [ability to rule out pancreatitis] of 67%." Feline pancreatitis and fPLI - making sense of sensitivity and specificity Lewis J Greendale Veterinary Diagnostics explains more about this and states "Disappointingly, studies released so far are not overly convincing for fPLI having a reliable role in the detection of the most common form of feline pancreatitis - chronic, low-grade pancreatitis. The studies currently available suggest that in a sample of 13 cats with known chronic, low-grade pancreatitis on histopathology, the fPLI test only showed ~50/50 chance of providing a correct diagnosis. Based on these figures, in practice this means that when using fPLI in mild pancreatitis, for every cat you correctly diagnose, you miss another altogether."

 

Another problem for people with CKD cats is that the result may be influenced by CKD. As mentioned above, many cats with pancreatitis have mildly elevated BUN and creatinine levels, and in some cases, it may be thought that these cats have CKD when actually they have pancreatitis. The reverse may also occur, i.e. cats with CKD may have elevated pancreatic enzymes even though they do not have pancreatitis.

 

The effect of naturally occurring renal insufficiency on serum pancreatic-specific lipase in cats (2013) Jaensh S Comparative Clinical Pathology 22(5) p801-803 looked at the effect of CKD on the Spec fPL test and found "Cats with azotaemia and cats with renal insufficiency had significantly higher mean SPEC fPL than cats without azotaemia or cats with pre-renal azotaemia... Cats with renal insufficiency had an elevated SPEC fPL in 50 % of cases, with 14% marginally elevated and 36% consistent with pancreatitis." The study concludes "This paper reveals increased pancreatic-specific lipase in cats with renal insufficiency, but not pre-renal azotaemia, and suggests a significant effect of renal insufficiency on serum pancreatic-specific lipase concentrations."

 

Therefore the test may not be as reliable in CKD cats, and mild elevations in fPLI in a CKD cat do not necessarily mean the cat has pancreatitis. However, the study does indicate that an fPL result of around 8 or above is suggestive of pancreatitis. If symptoms are also present, your vet might decide to err on the side of caution and treat for pancreatitis and see if your cat improves.

 

Snap fPL Test


IDEXX offers another test called the Snap fPL test. This basically tells you if your cat has a level above or below 3.5, i.e. whether the level is above the point at which pancreatitis becomes a possibility.

 

The advantage of this test is that it can be run in the vet's office with results within a few minutes. However, if the result comes back over 3.5, I would suggest then also having the Spec fPL test run as the Snap fPL test is slightly less accurate.

 

IDEXX explains more about the Snap fPL test.

 

IDEXX has detailed information about the comparative accuracy of the two tests.

 

PLI Test


The Pancreatic Lipase Immunoreactivity (PLI) test was the forerunner to the spec fPL test. It was patented by Texas A&M University (TAMU) and could therefore only be run by them.

 

This test was slightly more accurate than the spec fPL test at confirming pancreatitis in cats, but the cat needed to fast for 12 hours before having blood drawn for the test, and the results could take up to a week (although when we had it done for Harpsie, it took a dreadful 17 days!).

 

Texas A&M University no longer offers this test but instead uses the spec fPL test.

 


DGGR-LipaseTest


 

DGGR is a new assay which has recently been assessed for use in diagnosing pancreatitis in cats. Agreement of the serum Spec fPL and 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester lipase assay for the determination of serum lipase in cats with suspicion of pancreatiis (2013) Oppliger S, Hartnack S, Riond B, Reusch CE & Kook PH Journal of Veterinary Internal Medicine 27(5) pp1077-82 looked at DGGR-lipase activity and Spec fPL levels in 251 cats with clinical signs consistent with pancreatitis. The study concluded "Both lipase assays agreed substantially. DGGR assay seems a useful and cost-efficient method compared to the Spec fPL test."

 

A more recent study, Comparison of Serum Spec fPL and 1,2-0-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester assay in 60 cats using standardized assessment of pancreatic histology (2016) Oppliger S, Hilbe M, Hartnack S, Zini E, Reusch CE &, Kook PH Journal of Veterinary Internal Medicine 201(30) pp764 -770 also found that DGGR appears to be as accurate as the Spec fPL test.

 

Novel lipase assay for a rapid, inexpensive, and reliable diagnosis of pancreatitis in dogs and cats (2017) Lucibello TJ, McGrath C, Papakonstantinou S & O'Brien PJ reports on the studies and says the DGGR-Lipase test is much more cost effective. They paid 50 (euro) cents for it compared to 41 Euros for the Spec fPL.

 

Variants of this test are gradually being offered by a number of different laboratories, including Antech Laboratories, which apparently offers it as part of the standard Antech blood chemistry tests at no additional charge. However, I can find no information about it at all on Antech's website, so I am wondering if they are still offering it.

 

Biovet in Canada is offering the DGGR-Lipase test in all its laboratories (including possibly the USA). There is more information here.

 

Vetpath in Australia has been offering the test since 2015.

 

Eurolyser Diagnostics seems to be offering the test in Austria.

 

You probably will not be surprised to hear that Texas A&M University does not believe this test is as good as their fPLI test, and explains why in the link.

 

TLI Test


The trypsin-like immunoreactivity (TLI) test is an older test devised by Texas A&M University which measures two enzymes, trypsinogen and trypsin, which are only produced by the pancreas. A cat needs to fast for 12 hours before having blood drawn for this test.

 

TLI is not always elevated in cats with pancreatitis, so a normal TLI test does not rule out pancreatitis.

 

This test has been largely superseded by the spec fPL test.  If you have the spec fPL test run at TAMU, however, they may ask that you have this test done together with a folate test.

 

This test is the best way to check for exocrine pancreatic insufficiency (EPI). Chronic feline pancreatitis: cats are not small dogs (2011) Little S Presentation to the 36th World Small Animal Veterinary Association World Congress says "over time, cats with CP may develop exocrine pancreatic insufficiency and fTLI is useful for detection of this complication."

 

Batt Laboratories explains more about TLI and folate.

 

Cobalamin (Vitamin B12) and Folate Test


Up to 50% of cats with pancreatitis have below normal levels of folate, particularly if they are also suffering from IBD.

 

Cats with exocrine pancreatic insufficiency (EPI) may have normal levels of cobalamin but appear to do better if they are given supplements.

 

Batt Laboratories explains more about TLI and folate.

 

Texas A&M University can measure levels of cobalamin and folate, and explains why they are important.

 


Treatments


 

The cornerstones of treatment for cats with acute pancreatitis are:

  • fluid therapy

  • dietary management

  • pain control

For cats with chronic pancreatitis, treatment is often based on the symptoms, though any acute flare ups would need additional treatment.

 

Cats with exocrine pancreatic insufficiency (EPI). are normally treated with enzyme supplements and folate.

 

Treatment recommendations for feline pancreatitis (2016) is a paper from IDEXX.

 

Managing pancreatitis and concurrent conditions (2009) Robertson J DX Consult Winter 2009 pp12-13 discusses how to manage pancreatitis and common concurrent conditions such as IBD or diabetes.

Fluid Therapy


Cats with pancreatitis are often dehydrated, so fluid therapy is used to rehydrate them and make them feel better.

 

Intravenous fluids (IV or "a drip") at the vet's office may be used initially, and will usually be needed for several days or longer for cases of acute pancreatitis. Your vet should monitor your cat carefully for overhydration and hypokalaemia (low potassium levels).

 

Thereafter you may need to give subcutaneous fluids at home. Cats with pancreatitis may need subcutaneous fluids even if their kidney function is not reduced enough to warrant them in a normal CKD cat.

 

Diet


The most important thing is that your cat takes in food. Cats with pancreatitis are at high risk of hepatic lipidosis so food is essential and should be given as soon as the cat is rehydrated, usually after the first 12-24 hours on IV fluids.

 

Once your cat is home, you must continue to ensure your cat eats, preferably little and often. Your vet may prescribe a therapeutic diet such as Hill's i/d to help manage the condition. The phosphorus level is a little high for a CKD cat at around 0.80% (DMA basis), and it is not low fat at around 24%, but if your cat will eat it and can tolerate it, it could be a good choice to help your cat through the crisis.

 

Whether hospitalised or at home, some cats will require a feeding tube.

 

Fasting


Fasting has historically been part of the treatment plan for pancreatitis in humans and dogs. However, fasting does not seem to be particularly effective for cats, who have a physiological need to eat relatively frequently (and has fallen out of favour for dogs too). Managing pancreatitis and concurrent conditions (2009) Robertson J DX Consult Winter 2009 pp12-13 states "The historical recommendation of nothing per os (NPO) for animals with pancreatitis is no longer accepted."

 

Fasting can be problematic for CKD cats in particular because the lack of food may permit levels of stomach acid to rise. Feeding little and often is usually more effective, unless the cat cannot stop vomiting, in which case the vet will need to treat the cat in hospital.

 

Reduce Fat Intake


It is often recommended that humans and dogs with pancreatitis should reduce their fat intake, but there is no evidence that reducing fat intake is essential for cats. To feed or not to feed? Controversies in the nutritional management of pancreatitis (2016) Shmalberg J Today's Veterinary Practice Nov/Dec 2016 pp45-51 says "There is no evidence that dietary fat restriction is warranted in feline pancreatitis, whether acute or chronic. Therefore, higher fat recovery diets can be fed if palatable and available."

 

However, some people do find that feeding a lower fat diet does seem to help their cat, especially if their cat has IBD or diabetes, or if the pancreatitis is chronic.

 

Essential Fatty Acids


I've heard from a number of people who felt essential fatty acids did not agree with their cats with pancreatitis, causing problems such as diarrhoea. Potential adverse effects of Omega-3 fatty acids in dogs and cats (2013) Lenox CE & Bauer JE Journal of Veterinary Internal Medicine 27(2) states "Pancreatitis also is a concern when feeding high fat diets or high doses of fatty acid supplementation, especially in dogs with a known risk of pancreatitis. However, there are no reports of omega-3 fatty acid or fish oil supplements causing pancreatitis in dogs, cats, or humans. Theoretically, omega-3 fatty acids could prevent pancreatitis because of decreased blood triglyceride concentrations. An extremely high dosage of omega-3 fatty acids or a fish oil supplement in addition to a very high fat diet would likely be required to induce pancreatitis." It goes on to say "Clinical patients that develop diarrhea or other adverse gastrointestinal effects may need a decreased dosage of omega-3 fatty acids as well as other dietary modification."

 

An increased level of essential fatty acids compared to standard cat foods is one of the features of therapeutic kidney diets. If you wish to give additional essential fatty acids, ask your vet if they are appropriate for your cat.

 

Pain Medications


Pancreatitis can be very painful, though this may not be true in every case. Unfortunately cats often hide the fact that they are in pain (possible signs of pain in cats are discussed here), so it is usually safer to assume your cat is in pain until proven otherwise. Managing pancreatitis and concurrent conditions (2009) Robertson J DX Consult Winter 2009 pp12-13 states "Abdominal pain is rarely recognized in cats with pancreatitis. Nonetheless, many cats will show clinical improvement if provided analgesic therapy; therefore pain management should be provided to all cats with acute pancreatitis."

 

Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion says "If I diagnose an animal with acute pancreatitis, even if the patient does not show signs of pain, I begin pain management. I have been surprised by how many patients improve clinically with the only difference being pain management."

 

Cats with chronic pancreatitis may also feel and act better with pain medication. Managing pancreatitis and concurrent conditions (2009) Robertson J DX Consult Winter 2009 pp12-13 goes on to say "Cats with chronic pancreatitis may also benefit from pain management, and options for outpatient treatment include a fentanyl patch, sublingual buprenorphine, and oral butorphanol or tramadol." Discuss the provision of painkillers with your vet. If you find your cat seems brighter after being given them, chances are s/he was in pain.

 

Buprenorphine (Buprenex or Vetergesic) is a painkiller which appears safe to use in CKD cats when necessary, and which most people seem to find effective. You can read more about it here

 

Vitamin B12 (Methylcobalamin)


Pancreatitis may cause malabsorption of vitamin B12, particularly in cats who also have IBD, so supplements should be provided.

 

Cats with a condition called exocrine pancreatic insufficiency (EPI) require vitamin B12 supplements. Feline exocrine pancreatic insufficiency: a retrospective study of 150 cases (2016) Xenoulis PG, Zoran DL, Fosgate GT, Suchodolski JS & Steiner JM Journal of Feline Internal Medicine 30(6) pp1790-1797 states "those receiving cobalamin therapy were 3.0 times more likely to have a positive clinical response, whether or not they were hypocobalaminemic prior to treatment." The study concludes "Cobalamin should be supplemented in all feline EPI patients, even those whose test results demonstrate normocobalaminemia, because tissue cobalamin is depleted before hypocobalaminemia develops."

 

Most people with CKD cats find their cats do better if they are taking vitamin B12, so your cat with pancreatitis is probably already taking it, but if not, talk to your vet about starting it in the form of methylcobalamin.

 

Texas A&M University provides a treatment protocol if required.

 

Anti Nausea Medications


Cats with pancreatitis do not always vomit, but may be suffering from nausea. It is therefore often recommended that anti nausea medication should be given, and as with painkillers, many people find that their cats seem to do better when they are receiving these medications.

 

One commonly used anti nausea medication which is very effective is ondansetron (Zofran).

 

You may be offered metoclopramide (Reglan), which works by regulating stomach contractions, and therefore may be helpful for nausea caused by a lack of motility in the stomach; but since it can cross the blood/brain barrier, it can also act on the brain to control feelings of nausea. However, it appears that it is not actually particularly effective in cats. Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion states "I don’t use metoclopramide in cats anymore. I am not completely convinced it is that effective as an antiemetic in cats. Evidence suggests that cats don’t have dopamine receptors in the chemoreceptor trigger zone, which is metoclopramide’s site of action."

 

Please read the Nausea, Vomiting and Excess Stomach Acid page for more information on these medications.

 

Acid Blockers


There are several medications which can be most effective in excess controlling stomach acid, thus reducing vomiting and nausea, and increasing appetite.

 

Diagnosing and managing feline pancreatitis, a roundtable discussion (2008) Robertson J, Forman M, Steiner J, Twedt D & Williams D IDEXX Laboratories discusses whether these medications may be helpful for cats with pancreatitis, with opinion divided.

 

There is more information about these treatments here.

 

Antibiotics


Antibiotics have not been a routine treatment for cats with pancreatitis. Managing pancreatitis and concurrent conditions (2009) Robertson J DX Consult Winter 2009 pp12-13 says "Pancreatitis is usually a sterile process in cats and antibiotics are rarely indicated."

 

However, Current approaches to vomiting in cats and puppies (2013) Gaschen FP, Lee JA, Parnell N, Richter K, Tams TR, Twedt D & Gloyd K Pfizer Roundtable Discussion states "we identified bacteria in the pancreas of about 40% of cats with moderate to severe chronic or acute pancreatitis. Currently, my approach to a cat with chronic pancreatitis is cultures and histopathology. I usually start with antibiotic therapy because bacteria may play a role."

 

An antibiotic called metronidazole (Flagyl) may be prescribed because it has anti-inflammatory properties. It tastes utterly foul, so if your vet prescribes this, try to give it in a gelcap.

 

Mar Vista Vet has more information about metronidazole.

 

Pancreatic Enzyme Supplements


Some people with pancreatitis have reported that they experience less pain when given pancreatic enzyme supplements, though others have apparently felt worse. It is not known if the same applies to cats, but some vets do recommend trying them.

 

Feline acute pancreatitis: current concepts in diagnosis and therapy (2015) Armstrong PJ & Crain S Today's Veterinary Practice 5(1) pp22-32 states "Pancreatic enzyme supplements are used in some humans with chronic pancreatitis with normal exocrine pancreatic function because they are associated with decreased frequency and intensity of episodes of abdominal pain. This has not been investigated in cats, but there are anecdotal reports that this therapy improves appetite and gastrointestinal signs in cats with chronic pancreatitis."

 

If your vet does think you should try pancreatic enzyme supplements, Chronic diarrhoea in cats Gunn-Moore DA Purina Presentation recommends supplementation as follows for cats with chronic pancreatitis: "Replace pancreatic enzymes by adding pancreatic enzyme replacement to food (~ half a teaspoonful of powder per meal, or to effect, ideally incubating it with the food for 30 minutes before feeding to reduce the risk of lip irritation), or add fresh-frozen then defrosted pig pancreas (~20-40g per meal, or to effect)."

 

Pet Education explains more about how pancreatic enzyme supplements are sourced. Viokase is one commonly used brand.

 

Cats with a condition called exocrine pancreatic insufficiency (EPI) do require pancreatic enzyme supplements.

 

Obviously, if you feel the pancreatic enzyme supplements are making your cat worse, you should speak to the vet about stopping them.

 

Steroids


Since there is often inflammation present in cases of pancreatitis, corticosteroids may be prescribed to help dampen down the inflammation.

 

Diagnosing and managing feline pancreatitis, a roundtable discussion (2008) Robertson J, Forman M, Steiner J, Twedt D & Williams D IDEXX Laboratories discusses the use of steroids in pancreatitis and says "It is important that practitioners don't just give corticosteroids as a knee-jerk reaction. I only give corticosteroids while monitoring Spec fPL results. I want to have a Spec fPL result before I start therapy and 10 days later. If the cat is clinically improved and the Spec fPL decreases, I'll certainly continue. If the cat is better but the Spec fPL doesn't decrease, I reconsider. Similarly, if the Spec fPL decreases but the cat doesn't feel better, I think twice about corticosteroid use. If the Spec fPL increases and the cat doesn't feel better, I certainly stop corticosteroid use."

 

Your vet may want to start at a higher dose to reduce the inflammation, then reduce to a maintenance dose. If your cat can eventually come off the steroids, they should not be stopped suddenly, but rather the dose must be tapered. This is because using corticosteroids may suppress the adrenal glands' ability to produce cortisone naturally; so tapering the dose minimises the risk of adrenal insufficiency occurring as a result.

 

A commonly used corticosteroid in cats is pred (prednisone or prednisolone). Cats metabolise prednisolone better than prednisone (they have to convert prednisone into prednisolone in their bodies anyway before they can use it) so it is usually better to give prednisolone in the first place. Bioavailability and activity of prednisone and prednisolone in the feline patient (2004) Graham-Mize CA &  Rosser EJ Veterinary Dermatology 15 (s1), pp 10 supports this view.

 

The Treatments section has more information about steroids.

 

Probiotics


One study into humans with severe acute pancreatitis, Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised double-blind placebo-controlled trial (2008) Besselink MGH, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJM, Rosman C, Ploeg RJ, Brink MA, Schaapherder AFM, Dejong CHC, Wahab PJ, van Laarhoven CJHM, van der Harst E, van Eijck CHJ, Cuesta MA, Akkermans LMA, Gooszen HG The Lancet 371(9613) pp651-659, found that using probiotics more than doubled the risk of death.

 

The findings of this study have been debated and disputed. Use of probiotics in the treatment of severe acute pancreatitis: a systematic review and meta-analysis of randomized controlled trials (2014)Gou S, Yang Z, Liu T, Wu H, & Wang C Critical Care 18(2) R57 refers to the above trial, stating that the trial "showed that probiotics had harmful effects, which deterred the initiation of other trials on probiotics. In recent years, however, two other RCTs have been completed, with no negative consequences were in patients treated with probiotics. We therefore consider that the results of the PROPATRIA trial are questionable and that further meta-analyses of the more recent RCTs is required. To this end, we performed this meta-analysis on six select RCTs in order to determine the effects of probiotics on the rate of pancreatic and total infection, operation rate, length of hospital stay and mortality. In addition, we tried to determine the reason for the heterogeneous results across the different trials."

 

The study concludes "Probiotics showed neither beneficial nor adverse effects on the clinical outcomes of patients with predicted SAP. However, significant heterogeneity was noted between the trials reviewed with regard to the type, dose and treatment duration of probiotics, which may have contributed to the heterogeneity of the clinical outcomes. The current data are not sufficient to draw a conclusion regarding the effects of probiotics on patients with predicted SAP.'

 

These studies related to humans with acute pancreatitis, and may well not be applicable to cats, particularly cats with chronic pancreatitis. If you are using probiotics, talk to your vet about whether to continue with them.

 


Exocrine Pancreatic Insufficiency


 

Some cats with chronic pancreatitis may develop a condition called exocrine pancreatic insufficiency (EPI). This means that the pancreas is not producing enough pancreatic enzymes, which are necessary to process protein, fat and carbohydrates in the diet. It was previously thought that this condition was rare in cats but recent research indicates that it may be less rare than was previously thought (it may also develop in cats without pancreatitis).

 

Feline exocrine pancreatic insufficiency: a retrospective study of 150 cases (2016) Xenoulis PG, Zoran DL, Fosgate GT, Suchodolski JS & Steiner JM Journal of Feline Internal Medicine 30(6) pp1790-1797 looked at 150 cats with EPI and found that the most common symptom (91% of cats in the study) was weight loss; you may also see loose stools or poor coat condition. Equal numbers of cats (42%) in the study had either a poor appetite or an increased appetite.

 

The best way to diagnose EPI is via the fTLI test.

 

The usual treatment is to supplement pancreatic enzymes orally. The above study also found that it is important to give cobalamin (vitamin B12) because cats who received this as well as enzyme replacement did better, stating "those receiving cobalamin therapy were 3.0 times more likely to have a positive clinical response, whether or not they were hypocobalaminemic prior to treatment." The study concludes "Cobalamin should be supplemented in all feline EPI patients, even those whose test results demonstrate normocobalaminemia, because tissue cobalamin is depleted before hypocobalaminemia develops. The authors speculate that those cats with partial or poor response to ERT [enzyme replacement therapy] may have not been concurrently supplemented with cobalamin."

 

Pet MD explains more about the condition.

 

Exocrine pancreatic insufficiency in small animals (2016) Steiner J Merck Veterinary Manual has a good overview of EPI.

 


Support


 

Feline Pancreatitis Support Group is a support group for people dealing with pancreatitis in their cat. This group has open archives, i.e. if you post a message, it is visible to anyone online.

 

 

Back to Page Index

 

This page last updated: 04 June 2017

 

Links on this page last checked: 04 June 2017

 

 

   

*****

 

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.

 

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