3. Controlling secondary hyperparathyroidism

• phosphorus control

• Calcitriol

• Sensipar

4. Use of benazepril (Fortekor) and other ACE inhibitors (enalapril or Enacard) 

• what are ACE inhibitors

• how do they work?

• clinical trials

• cautions

• websites

4. Oral adsorbents

• Ipakitine/Epakitin

  • what is Ipakitine/Epakitin?

  • how does it work?

  • when and how is Ipakitine/Epakitin used?

  • clinical trials

  • cautions

  • websites

   

• Kremezin (AST-120)

5. Kidney transplants

• a treatment, not a cure

• ethical considerations

• availability

Purposes of Treatment

The purposes of treatment are firstly, to try to prolong life; and secondly, to try to make the patient more comfortable. Even if the former is not possible for any length of time, the latter remains an important aspect of caring for a CRF cat. Try to be proactive in treating your cat - keep a close eye out for symptoms and start treating any that arise as soon as possible. At the same time, you may find that some treatments are too stressful for your cat - they all are individuals, and some cope better than others. Even if you decide not to use some treatments, you should be able to use others, so just do the best you can, and check the Tips on Medicating Your Cat page for tips on how to make medicating your cat easier for both of you.

Many CRF cats hide; see Symptoms for an explanation of this behaviour. Once you implement a treatment programme and your cat begins to feel better, you should find your cat hides less, though s/he may still require more quiet time than was previously the case.

Cats whose coats have changed colour may also regain their old colour as you get the CRF under control.

Finding A Good Vet

If you want to be able to give your cat the best possible treatment, you need a good vet, with whom you can work in partnership. A good vet can make all the difference to your cat's quality of life and chances of survival. I do not wish to disparage vets, who work very hard to qualify, and most of whom genuinely love animals; but as in every other profession, some vets are good, others not so good, and a small percentage very poor, so it is essential that you can recognise a bad vet - your cat's life depends upon finding a good one.  But even the best vet may not have time to keep fully up to date on developments in the treatment of CRF, so it may be helpful for you to find recent reference articles for your vet to read, for example.  

I maintain a private list of British vets who permit sub-Qs when appropriate. If you are in the UK and need such a vet, please read here about how to obtain details of any vets in your area, though unfortunately the list is very short, so the chances of such a vet being in your area are sadly rather low.

Special Needs Pets has useful information on choosing a vet, and on working together with him or her.  

Veterinary Partner also has helpful suggestions on finding a good vet.

Linda's Feline CRF Hints also has helpful suggestions.

Vet Recommendations is a list of vets recommended by people with CRF cats (most of these vets are in the USA).

Feline Good gives details of the five British specialists in feline medicine (Sarah Caney is no longer in Hampshire).

The Feline Advisory Bureau gives details of feline residents which it sponsors at a number of British veterinary schools.

The American Veterinary Medical Association mentions that if you change vets, your previous vet is obliged to provide copies of your cat's medical records if requested (see Section VII D).

A Second Opinion

If you are concerned about your vet's approach, you may wish to seek a second opinion. This is not always easy, but there are a couple of online options available:

Cornell University College of Veterinary Medicine Dr Louis J Camuti Memorial Feline Consultation Service offers advice on feline health related issues. You need to provide as much information as possible (e.g. blood test results), then the consultant will contact you or your vet to discuss your cat's situation, usually on the same day that you contact them. The service costs US$55 and is available Mondays, Wednesdays, and Fridays, 9 a.m. - 12 p.m. and 2 p.m. - 4p.m. Eastern time (not holidays). Cornell has an excellent reputation, and I have heard from several people who have used this service, most of whom were very satisfied.

Dr Nik Weber, a specialist in feline medicine, will consult with you or your vet for US$150. He will not undermine your vet or his/her advice, but rather he aims to provide additional input for difficult cases, particularly where there are no specialists locally. Dr Weber will consult internationally. A lady I have "known" (online) for some years has used him as her primary vet in the past and speaks highly of him.

Keeping Records

However good your vet is, I strongly recommend keeping your own records of your cat's symptoms and behaviour on a daily basis, together with bloodwork results and which treatments you tried - this can help you to monitor trends, and can also serve as a reminder of what treatments worked should a symptom recur some months later. Cori has devised a helpful Excel record for this purpose which can be found here (you can read about Cori and her CRF cat, Ebony, on the Success Stories page).

Obtaining Medications

The Obtaining Supplies Cheaply page has tips on obtaining medications at reasonable prices in the UK, USA and Canada. The Medicating Your Cat page has information on how best to medicate your cat with the least stress for both of you. It also has tips on possible drug interactions.

DO NOT GIVE YOUR CAT ANY MEDICATION WITHOUT FIRST OBTAINING YOUR VET'S APPROVAL.

Regulation of Fluid Levels in the Body

Fluid Therapy

Incontinence

This may sometimes be caused by either a urinary tract infection or occasionally by a kidney infection (pyelonephritis). A urine culture and sensitivity test should show the presence of a urinary tract infection, but will not detect kidney infections. One of our cats, Harpsie, is prone to kidney infections, partly because he has PKD (in PKD cats, the bacteria can enter the cysts in the kidneys and cause a deep-rooted infection). We always know when Harpsie has a kidney infection because he becomes incontinent, but the incontinence goes away when the infection is treated for 4-6 weeks with antibiotics.

Washington State University College of Veterinary Medicine mentions that antibiotic treatment should continue for 6-8 weeks in the case of kidney infections.

Urinary tract infection: how to diagnose and treat correctly (2003) is a presentation by Claudio Brovida to the World Small Animal Veterinary Association World Congress 2003, which explains why lengthy courses of treatment are sometimes necessary.

If there is no infection present, you might want to try using Vitamin B12 in the form of methylcobalamin in case that helps - some Feline CRF Information listmembers have found it helpful. See Food Composition and Nutritional Requirements for more information on vitamin B.

Please also read the Inappropriate Elimination section below in case some  of it applies to your cat's situation, and for tips on dealing with the problem from a practical perspective.

While you are trying to resolve the problem, you may wish to consider using incontinence supplies.

Incontinence Supplies

UK

Boots the Chemist sells a waterproof sheet for a double bed for £29.99; you might wish to place this over a bed during the day, with a blanket on top which can be easily washed.

Daxon (0870 900 1234 UK only) sells 30 human incontinence pads 60cm x 60cm for £14.99. 

If you go to a DIY store, they often sell plastic sheeting to protect your furnishings when decorating. It is really thin, like those bags used for fresh fruit and vegetables in supermarkets. It comes on a roll about 18ft long and 6 ft wide, and costs about £3 ($5). I used this stuff to cover the bed for Ollie, it was wide enough for my king size bed and I just cut it to the right length. It's so fine that you can't feel it on the bed, but it helps protect the bed, although urine can pool in it to a degree, plus it is so fine that it might slip off the bed, so I used mine in conjunction with a washable throw on top.

USA

Joybies sells piddle pants for cats in several sizes.

Pet Diapers sells pet diapers in a number of sizes.

JB Pet Supplies sells puppy pads in a variety of sizes.

Direct Medical sells human underpads and bedpads, which usually work out cheaper, although you do have to buy a lot.

Amazon sells rubber-backed waterproof sheeting.

Inappropriate Elimination

There can be various reasons for a cat urinating (and sometimes defecating) in the wrong place. Sometimes this is a behavioural problem, but there may be some other reason for it in a CRF cat. Firstly and most importantly, it can be as a result of a urinary tract infection (UTI) or constipation, whereby the cat associates the litter box with the pain of the UTI or constipation, so starts urinating and/or defecating elsewhere. You should also consider the possibility of a kidney infection - our cat is prone to them and leaks urine uncontrollably when he has one. Infections and constipation can be very painful, and UTIs and kidney infections may also damage your cat's kidneys further, so if your cat urinates or defecates in the wrong place more than once, you should go to the vet as soon as possible in order to have tests done and treatment begun if necessary. 

Secondly, inappropriate elimination can be associated with the general weakness and weight loss of a CRF cat. If your litter box has a high edge, it might simply be too hard for your cat to clamber into. Try to provide a lower litter box and see if this makes a difference. 

Thirdly, the weight loss of CRF can make your cat's paw pads rather tender, which makes standing on litter uncomfortable. This can be remedied by providing softer litter, or by placing a few layers of newspaper on top of the litter which can easily be thrown away with the litter.

Fourthly, in view of their increased need to urinate, many cats simply get "caught short" and cannot make it to the litter box in time. This is easily remedied by placing several litter boxes in various locations, including on every level if your home has more than one floor, and/or by using larger litter trays.  You may also need to clean the litter boxes more often or provide more to offset the increased urination, so the cat always has a clean place in which to go.

If you have recently had new carpets laid, it is possible that the carpet actually has a urine-type aroma to the cat, which leads the cat to associate the carpets with the litter tray and urinate on them. New carpet smells like smelly urine? has more information on this intriguing possibility.

If none of these approaches helps, you need to consider the possibility of a behavioural problem not necessarily related to the CRF. As a rule of thumb, in a multi-cat household you need one litter tray per cat, plus one. Some cats prefer one litter tray to urinate in and a separate one to defecate in, and some cats like a covered litter tray, while others prefer uncovered; almost all cats prefer a tray out of the way of household traffic which offers some degree of privacy. For most cats, the bigger the litter tray, the better. Some people have had good results with a particular type of litter which is supposed to appeal to cats called Cat Attract. Try to keep the trays as clean as possible (although be careful not to clean them too much; they need to retain toileting associations for the cat), and experiment with the type of litter you use.

If your cat has been urinating in one particular spot, you need to clean it very thoroughly to remove all traces of the smell - even if you can no longer smell it, your cat, with his/her better sense of smell, probably can. Ideally you need an enzymatic cleaner which really remove the smell, though of course you must make sure you do not use a product which is harmful to cats. A product called Anti-Icky-Poo (available to purchase online in the USA here, and has a link for purchasing it in the UK)  has an excellent reputation. After the area is completely dry, try putting a litter box in the cat's chosen spot, or if that is not possible try a food bowl (cats usually do not urinate where they eat), a pot plant or aluminium foil (cats do not like the texture). 

Unfortunately, for some CRF cats, urinating and/or defecating inappropriately continues regardless of any measures you might take, and you may have to grit your teeth, minimise access to favoured zones and try to focus on the fact that this is related to the illness in some way and your cat probably can't help his or her behaviour.  We had to do this with Tanya, who seemed to get caught short, but we figured twelve years of her love more than compensated us for her behaviour. You may derive some comfort from knowing that, since CRF cats have dilute urine, most of their accidents only have a mild smell, if any. For cats who urinate on beds or sofas, try limiting their access to such areas by closing doors, or if you are reluctant to do this, cover the bed or sofa with incontinence pads or a plastic sheet (see incontinence supplies), and put a machine-washable blanket on top for the cat to lie on; this will protect the bed and so reduce your stress levels, whilst allowing the cat to lie on a comfortable but easily washed blanket. Please, do NOT rub your cat's nose in the accident, it is extremely cruel and achieves nothing, cats do not associate the punishment with their behaviour. 

Hilltop Animal Hospital has excellent information from Dr Karen Overall, a famous US animal behaviourist. 

Hilltop Animal Hospital also has a series of four other articles with advice on dealing with such problems.

Association of Pet Behaviour Counsellors has a very helpful article by one of its members, David Appleby.

Emergency respiratory assessment (2001) Hughes D is a presentation to the World Small Animal Veterinary Association World Congress 2001. It is rather technical but may still be of use.

Virginia-Maryland Regional College of Veterinary Medicine has examples of breath sounds, including the sound a cat with pulmonary oedema makes.

Some vets recommend the use of antacids, such as Tums or Mylanta. Some products in this family do actually work well in CRF cats as phosphorus binders, but they are not usually strong enough to help control stomach acid.

Slippery Elm Bark

If you wish to pursue natural methods of controlling stomach acid and the accompanying vomiting, nausea and loss of appetite, Slippery Elm Bark (SEB) is often very effective; it can also help with constipation. The Holistic Treatments page has more information on SEB.

Use of Acid Blockers: Pepcid AC/Zantac 75/Tagamet

There are several medications which can be most effective in controlling stomach acid, thus reducing vomiting and nausea, and increasing 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 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 265 (US: 3.0).

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 CRF, 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 CRF cats (scroll to the end).

Famotidine (Pepcid AC)

Pepcid AC is the most commonly used medication for feline CRF-related stomach acid problems in the USA, and it is a very effective treatment. The active ingredient is famotidine USP, and Pepcid AC (Regular Strength) contains 10mg. Pepcid may be sold under a different name in your country (e.g. Amfamox in New Zealand and Australia).

Pepcid AC Dosages

Pepcid AC is excreted by the kidneys, and cats with CRF cannot process it as efficiently as healthy cats. This means that levels of Pepcid 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) CRF 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 CRF cats (scroll to the end).

Below are suggestions for Pepcid AC dosages for CRF cats, but be guided by your vet. You should only use Pepcid AC with your vet's approval. Do not start with the maximum dose, it could be risky.

 

Starting dose:	Quarter of a 10mg tablet once every other day (i.e. 2.5mg once every two days e.g. on Mon, Wed, Fri)
Intermediate dose (if starting dose does not seem to be helping):	Quarter of a 10mg tablet once a day (i.e. 2.5mg once a day)
Maximum dose:	Quarter of a 10mg tablet twice a day (i.e. 5mg a day in total)

Pepcid tastes quite bitter, so you may find it easier to give it in a gelcap. Many people prefer to give it at night because this seems to help cats who vomit at night or first thing in the morning. It usually takes effect pretty quickly.

Some cats, particularly those with high bloodwork (creatinine over 5), do not do well on Pepcid AC, perhaps because their kidneys cannot excrete it efficiently as described above. These cats may in fact exhibit increased vomiting when given it (Drugs.com mentions how an overdose may cause vomiting) - this happened to our Thomas. Pepcid may also adversely affect cats with existing heart rhythm problems. In such cases you may wish to ask your vet about using ranitidine (Zantac 75) instead.

Please note, you need Pepcid AC but not the chewable type, and not other similar products with Pepcid in the name such as Pepcid Complete - the other versions have some ingredients which make them unsuitable for CRF 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).

If you are giving Pepcid at the same time as sucralfate (Carafate or Antepsin), phosphorus binders, ACE inhibitors or metoclopramide (Reglan),  you should separate the dosing by at least two hours, since, according to Plumb's Veterinary Drug Handbook, these other medications may bind with the Pepcid and thereby reduce its effectiveness.

Unfortunately, it appears that 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 CRF cats. Pepcid AC used to be kept behind the counter rather than displayed on a self-service shelf, so you could ask the pharmacist if there is any Pepcid AC left in stock; if not, famotidine exists in generic form, but only in 20mg size, which could be difficult to cut; plus it requires a prescription from your vet.

General Medical shows which trade names Pepcid is known by in other countries.

Veterinary Partner has more information on Pepcid AC, and mentions how it may adversely affect cats with heart rhythm problems.

Pet Place has more information about Pepcid AC.

Ranitidine (Zantac 75)

A very small number of cats will experience increased vomiting with Pepcid AC. In these cases, you may wish - with your vet's approval - to try another histamine H2 antagonist, also available over the counter, called Zantac 75. The active ingredient in Zantac is ranitidine 75mg, and it works in a similar way to Pepcid AC.

One problem with Zantac is dividing the tablets up into cat-sized dosages: the usual dose is 0.25 to 1.00 mg per pound up to twice a day, so for a ten pound cat, you can give up to an eighth of a tablet twice a day with your vet's approval. Some people give up to twice this amount, but as with Pepcid, I suggest starting low and increasing the dose if necessary since Zantac is also excreted by the kidneys. 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. There is also a liquid (syrup) form of Zantac, but this is peppermint flavoured, so not many cats would like it, plus you need a prescription for it.

There is also an injectible form of ranitidine, but I do not have details of dosage for this.

Zantac may also help some cats with constipation, see above for more information.

Pet Place has more information about Zantac.

Cimetidine (Tagamet)

You may be offered another drug in this family called Tagamet (cimetidine). Tagamet has many more drug interactions than either Pepcid or Zantac, including with Norvasc (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 Pepcid AC or Zantac instead. 

The effects of cimetidine on renal function in patients with renal failure (1980) Larsson R, Bodemar G, Kagedal B, Walan A, Acta medica Scandinavica 208 (1-2) pp27-31 explains that Tagamet (cimetidine) may cause an increase in creatinine levels. If your cat's creatinine levels rise while using Tagamet, you may find they improve once you stop the medication.

Pet Place has information about Tagamet. 

Metoclopramide (Reglan)

You may also be offered Reglan, which is available by prescription only. This medication works in a different way to acid blockers - as its name suggests, it works by regulating stomach contractions, and therefore may help with nausea caused by a lack of motility in the stomach. Since Reglan can cross the blood/brain barrier, it also acts on the brain to control feelings of nausea. Reglan comes in 10 and 5mg tablets or a liquid, and must be given 20-30 minutes before eating. It may have various side effects, including constipation (so you might wish to try Slippery Elm Bark first), hyperactivity and agitation or drowsiness; very occasionally, twitching may be seen. Reglan also lowers the seizure threshold, so should not be given to cats prone to seizures (see Symptoms for a description of seizures).

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 CRF cats is normally caused by 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 Reglan for longer than three months.

If you are giving Reglan at the same time as Pepcid AC, you should separate the dosing by at least two hours, since Reglan may bind with the Pepcid AC and thereby reduce its effectiveness.

Veterinary Partner has more information on Reglan.

Pet Place also has some information.

Zofran (Ondansetron)

For cats who cannot take Reglan, e.g. cats who are prone to seizures, ondansetron is a possible alternative. It works in a different way to Reglan (it selectively inhibits serotonin 5HT3 receptors) so it does not lower the seizure threshold as Reglan does. This drug is commonly used to control vomiting in cats with pancreatitis or cancer, and is usually very effective. It can be given orally or by injection. I first heard of somebody using it in a CRF cat in 2002. Its use is still uncommon, not least because the drug was very expensive until the generic version recently became available, but it is slowly becoming more popular.

Pet Place discusses Zofran and mentions that the usual dose for cats is 0.11mg per pound bodyweight every 8-12 hours.

Merck Veterinary Manual has some brief information about Zofran.

Maropitant (Cerenia)

Maropitant is a new treatment from Pfizer. It is approved for the treatment of vomiting and nausea in dogs but is sometimes used off label in cats. 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.

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.

A commonly used dose appears to be 1mg per kg (2.2lbs) of body weight for the injectible form; Plumbs Veterinary Drug Handbook mentions that the dose for the pill form may be twice as high at 2mg per kg (2.2 lbs) of body weight. 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 manufacturers recommend 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 one study on cats, Safety, pharmacokinetics and use of the novel NK-1 receptor antagonist maropitant (Cerenia) for the prevention of emesis and motion sickness in cats (2008) Hickman MA, Cox SR, Mahabir S, Miskell C, Lin J, Bunger A, McCall RB Journal of Veterinary Pharmacology and Therapeutics 31(3) pp220-9, it was used for fifteen days without a break with no apparent problems. Be guided by your vet on the best approach for your cat.  

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 University of Zürich Institute for Veterinary Pharmacology and Toxicology warns (in German) that maropitant should not be used with calcium channel blockers such as amlodipine  (Norvasc or Istin, commonly used to treat high blood pressure in CRF cats). It also warns that urgent medical attention should be sought if maropitant gets in the eyes.

Pfizer product information sheet (tablets) mentions that maropitant should only be given for five days.

Pfizer product information sheet (injectible) also mentions this.

Drs Foster and Smith have an information sheet about the use of maropitant in dogs.

Pepto-Bismol

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.

Pet Education has more information on Pepto-Bismol.

Raising your Cat's Bowls

Normally a cat eats with the mouth lower than the stomach, but in CRF 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 US$23.

Drs Foster & Smith sell a cast iron raised food bowl stand from US$19.99. They also sell some other raised bowls.

Feeding Before Bedtime

You may occasionally find that your cat has more stomach upsets at night which cause vomiting during the night or first thing in the morning. If this happens, as well as 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. 

Mouth Ulcers

If you want to try holistic methods, Slippery Elm Bark, which as mentioned above can help with stomach acid, can also be made into a syrup and used to help heal mouth ulcers - this has been found to be a very effective treatment by many people on the Feline CRF Information list. See Holistic Treatments for more information about Slippery Elm Bark and how to make the syrup.

Another natural remedy for mouth ulcers is to mix white cheddar cheese with water to make a paste and spread it on the gums. The enzymes in the white cheddar cheese are supposed to eat the bacteria and help alleviate the infection, though I have not tried this myself and would not recommend it for dental problems other than mouth ulcers (see Related Diseases for more information on dealing with dental problems generally). I did try Eel Serum homeopathic remedy for Tanya, and I would say it did help, though perhaps not as much as the SEB might have done.

For severe mouth ulcers, antibiotics may be necessary; while for really obstinate ulcers, particularly in End Stage Renal Disease, you may need to consider using a treatment called sucralfate, which forms a protective coating over the ulcers and allows them to heal. Trade names for this drug include Antepsin in the UK, Carafate in the USA and Ulcogant in Germany. If you are giving sucralfate at the same time as Pepcid AC, Zantac 75 or Tagamet you should separate the dosing by at least two hours, since the sucralfate may bind with the Pepcid and thereby reduce its effectiveness.

Mar Vista Vet has information about sucralfate.

Gastro-Intestinal Bleeding

Slippery Elm Bark, which as mentioned above can help with stomach acid, may also help with some cases of gastro-intestinal bleeding.

Sucralfate may also be used to treat gastro-intestinal bleeding. It forms a protective coating over the ulcerated areas of the stomach and allows them to heal. Trade names for this drug include Antepsin in the UK, Carafate in the USA and Ulcogant in Germany. You should give sucralfate on an empty stomach in order for it to work properly, and if you are giving sucralfate at the same time as Pepcid AC, you should separate the dosing by at least two hours, since the sucralfate may bind with the Pepcid and thereby reduce its effectiveness.

Mar Vista Vet has information about sucralfate.

If the gastro-intestinal bleeding has caused severe anaemia, your cat might also need a blood transfusion to tide him or her over the crisis.

Diarrhoea

In many cases, diarrhoea will only last for a day. However, if it goes on any longer, or stops and then starts again, I'd recommend a trip to the vet because the cat may become quickly dehydrated (which does not only mean water loss, the cat may also be losing potassium).

Slippery Elm Bark appears to be able to help with both diarrhoea and constipation. It soothes the lining of the gut and gives the digestive system time to heal. Psyllium may also help (see constipation).

If the diarrhoea is a result of changing food too suddenly, stop feeding the new food and go back to your cat's old food until the problem is under control. Then gradually re-introduce the new food as described in Which Foods to Feed.

If your vet agrees, you can try a medication containing pectin and kaolin for a few days. However, be sure you use a formulation suitable for cats; kaopectate used to be suitable, but as the American Medical Veterinary Association explains, the formulation has changed and is no longer safe for cats. Pet Pectillin is a brand of pectin and kaolin which is safe for cats. Jeffers Pet sells another brand called KPAD Kaolin Pectin.

If the diarrhoea is caused by antibiotics, you may need to re-balance the bacteria in the gut. A small amount of natural, unflavoured yoghurt may help, but since many cats are lactose intolerant, there is a risk that this might actually make the diarrhoea worse. You may therefore find it easier to buy a commercial product in capsule form instead. One popular probiotic brand on the Feline CRF Information list is Culturelle, which contains lactobacillus. A typical feline dose is half a capsule in the morning and half a capsule in the evening while the cat is on antibiotics, but check with your vet. An alternative brand, designed especially for pets, is Benebac, available from Revival Animal Health among others. Fortiflora is another option, available from Entirely Pets.

Consumer Lab has a report on what probiotics do and how to choose one.

Probiotics are currently being considered as a treatment for CRF in their own right; see the Azodyl section for more information.

Occasionally a cat may appear to have diarrhoea, but it is in fact constipation with a small amount of liquid squeezing around the hard stool. This requires treatment for constipation.

Although loperamide (Imodium) is available without a prescription, please do not use it without your vet's knowledge and approval. According to Pet Place, it is a controversial treatment for animals, and can cause side effects in some cats, particularly those suffering from certain conditions including renal failure. It is also hard to work out a cat-sized dose. Other treatments outlined here are much safer.

Baker's Dozen has some suggestions for a bland short-term diet suitable for a cat with diarrhoea.

Bad Breath

Bad breath will often improve as dehydration is treated and the toxin levels in the body are controlled (see above). Please do keep an eye on your cat's mouth though, because dental problems are fairly common in CRF cats: in fact, in some cases dental problems are thought to play a major role in triggering CRF - see Related Diseases for more information on this. If your cat seems to have a sore mouth despite receiving treatment prescribed by your vet, please contact your vet.

Itching

Treating the uraemia will usually reduce the toxin levels and stop the itching. If your cat has high phosphorus levels, reducing these can also help. Occasionally itching may be related to low levels of Vitamin B6, in which case you should discuss supplementation with your vet.

Howling (Particularly at Night)

If this is caused by high toxin levels, it may well decrease in frequency and volume as you get the toxins under control with fluid therapy and by controlling stomach acid. If you suspect, however, that your cat may be deaf, have a hyperactive thyroid or have high blood pressure, which can also cause howling, you should see your vet for a diagnosis and appropriate treatment. 

Some cats unfortunately just howl, and it may be an old-age related problem known as cognitive dysfunction (sometimes referred to as feline Alzheimers). My vet told me that sometimes old cats wake up and feel a little confused, are not sure where they are, so they howl for reassurance; once they hear your voice, they feel comforted and will usually stop howling. Certainly both Tanya and Thomas were night howlers with no obvious reason for it (apart, in Thomas's case, from a keen desire to go outside at all hours!), and if we spoke to them they usually stopped.

A drug called selegeline or selegiline (Anipryl) is sometimes used to treat cognitive dysfunction in dogs, but the treatment is still experimental in cats, and may be contraindicated for cats with CRF.

Aktivait, a nutraceutical containing essential fatty acids and antioxidants, has been found in one trial to help dogs with cognitive dysfunction. I have heard from one vet who has also found it helpful in cats with this condition. Vet on the Web has an article by Sarah Heath, a veterinary behaviourist, who explains more about cognitive dysfunction and the use of Aktivait.

Feline Advisory Bureau has some information about senility in cats.

Mar Vista Vet has some information on the use of selegeline in animals.  

Pet Place also has information about selegiline use in animals.

The Cat Site talks about the experiences of one cat who participated in a study into the use of selegiline in cats.

The Regulation of Electrolytes in the Body

Weakness/Loss of Muscle

Treating metabolic acidosis can make a big difference to your cat's muscle tone; you should also consider the possibility of potassium problems, particularly in the case of weak back legs.  Problems with high phosphorus resulting in secondary hyperparathyroidism can also cause weakness. For more generalised weakness, you may wish to consider the use of steroids, which you are very likely to be offered automatically by most UK vets.

Steroids

Your vet may offer you steroids, either for a specific purpose, or as a general "pick me up".

If a cat is receiving regular sub-Qs, some vets add potassium supplements to the fluid bag, but this is not recommended because giving potassium in this way can sting a lot.

David Jacobson's Pages provide more information about the types of potassium supplement available in the USA.

Unfortunately potassium supplements can make some cats vomit more - after all, potassium is a salt, and salt would give anyone a stomach upset if taken neat. They may also cause diarrhoea in some cats. The solution is to try to spread them out more and mix them in with foods. If the problem persists, ask your vet about changing the brand and/or formula you are using in case that helps.

A potassium supplement may be needed even if the potassium level is technically still in the normal range. This is because, as discussed on the What Do All Those Test Results Mean? page, potassium is used in the cells of the body; but it is measured in the blood. The body pulls potassium out of the cells if necessary to maintain levels in the blood; so bloodwork may look fine but in fact the cat is deficient in potassium where it really needs it, at cellular level. 

Low potassium levels have only recently been recognised as having quite such a big effect on CRF cats, so it is quite possible that your vet will not be aware of this and might not suggest any potassium supplement, let alone one where potassium levels are ostensibly normal, but please do  discuss supplementing potassium with your vet if it falls below the middle of normal, usually about 4.4 mmol/L/l (US: mEq/l). If your cat also has metabolic acidosis, this is even more important, because, according to Dr David Polzin, "potassium depletion and metabolic acidosis may promote potentially fatal reductions in plasma taurine concentrations in cats."

But do NOT administer potassium supplements without your vet's approval - an overdose of potassium can cause heart failure, and it is not recommended to give potassium to a cat with a high creatinine level (above 500, USA above 6) without the cat being monitored closely by a heart specialist. Cats with creatinine at this level often have high levels of potassium and do not require a potassium supplement anyway. Potassium should also never be given to a cat who cannot urinate. Even when given to a cat without these complications, Dr David Polzin, a professor of veterinary internal medicine, recommends that potassium levels should be monitored every 24-48 hours when first beginning to supplement, and thereafter every 7-14 days.

Treating High Potassium (Hyperkalaemia)

Quite often bloodwork may indicate high potassium levels when in fact it is an error caused by a haemolysed blood sample or by leaving the blood for a while before testing it. Your vet may therefore choose to re-run the test to be sure that you really are dealing with high potassium.

If, however, your cat does indeed have high potassium levels (which is relatively common in cats with creatinine over 5), it is important to try to reduce them, because a level above 6 can cause problems with the electrical signals in the heart, and in the worst case scenario a cat with severe hyperkalaemia could have seizures or even a heart attack. Unfortunately it is not always easy to control hyperkalaemia, particularly if your cat is no longer urinating much or at all. The first thing to do, of course, is to stop all potassium supplements, plus increased fluid therapy may help; you may need to use saline fluid rather than other types such as LRS, which often contain potassium. Using benazepril (Fortekor) may increase potassium levels, so you may need to reduce or stop this treatment, although you should only do this with veterinary approval and you may need to reduce the drug gradually rather than suddenly. 

For really high potassium levels, sometimes insulin may be administered in conjunction with dextrose or sodium bicarbonate, which work together to move potassium intra-cellularly. Sometimes diuretics such as Lasix (furosemide) may be suggested by your vet, particularly if your cat has oliguria (reduced urination), in an attempt to get urine flowing again. Petplace reports that albuterol, a bronchodilator commonly used to help open the airways during asthma attacks, has also been used in treating hyperkalaemia associated with CRF.

In extreme cases, your vet may choose to use a potassium exchange resin: one CRF list member successfully used a human drug called sodium polystyrene sulfonate (Potassium Kayexolate) which has apparently been used to a limited extent in dogs but I do not know of anybody else who has used this for a cat. Potassium levels need to be monitored daily when using this treatment.  

Doyle Medical has information on the use of these drugs in human emergency medicine, scroll down to Treatment of Hyperkalaemia Using Insulin.

Washington State University discusses controlling hyperkalaemia in cases of Acute Renal Failure (click on Treatment, scroll down to Hyperkalaemia; there is also information further on, under Maintaining Normal Hydration).

Medline discusses high potassium in humans, but the basic principles are similar for cats.

E Medicine is a human site with information on hyperkalaemia.

Endocrine Emergencies is a presentation by Dr MS Wallace to the Atlantic Coast Veterinary Conference 2001.

RX Care of Canada has information on sodium polystyrene sulfonate, including how it works and possible side effects.

Metabolic Acidosis

If you are giving sub-Q fluids,  using Lactated Ringers Solution (LRS) may be sufficient to correct mild acidosis, because the lactate is metabolised by the liver where it is converted to bicarbonate, which helps correct the acidosis.

For more severe acidosis, potassium citrate is an effective treatment and may be used to treat low potassium as well. One downside to this is that you may need to watch for crystals forming in your cat's urine. It should also not be used or its usage should be stopped for cats with high potassium levels. If you are using potassium citrate, you should give it at least two hours apart from any phosphorus binders containing aluminium, because citrate may increase the absorption of aluminium.

Another way of treating acidosis is by using bicarbonate of soda or baking soda (sodium bicarbonate), which replenishes the bicarbonate lost from the body in CRF. Even if acidosis is not severe, it can be worth taking steps to control it and to limit the chances of it progressing further. When Thomas was particularly poorly, my vet recommended giving him the following to drink:

• 10 fluid ounces (0.3l) of water

• 2 tbsps powdered glucose (available from chemists)

• 1 pinch of salt 

• 1 pinch of bicarbonate of soda (available in the baking section of supermarkets)

Not every cat will drink this but it can be worth trying. If you would prefer to give the bicarbonate of soda in a gelcap, Dr Kathy suggests an initial dose of 5-10mg per kg of body weight every twelve hours (a kg is 2.2 lbs). Dr David Polzin suggests a similar but slightly higher initial dose of 8 to 12 mg/kg body weight every 8 to 12 hours.

Do not give your cat bicarbonate of soda without your vet's approval, since too much can cause the opposite problem of excess alkalinity, which can be very dangerous. 

Regulation of Minerals in the Body

Treating High Phosphorus - Why This is Important 

Many CRF cats have high levels of phosphorus because the kidneys can no longer efficiently excrete it: this is known as hyperphosphataemia. Hyperphosphataemia can make the cat feel worse and can also make the CRF progress faster, in many cases resulting in secondary hyperparathyroidism. In one study, Survival of cats with naturally occurring chronic renal failure: effect of dietary management (2000) Elliott J, Rawlings JM, Markwell PJ, Barber PJ Journal of Small Animal Practice 41(6) pp235-242, cats eating a low phosphorus diet, with added binders where necessary, lived more than twice as long as those who did not. Thus it is important to try and keep phosphorus levels low, but unfortunately, some vets do not appear to be aware of just how important this is.  

You should try to reduce the amounts of phosphorus in your cat's diet (see Food Composition and Nutritional Requirements for more information) but often it also eventually becomes necessary to use a phosphorus binder, which binds with the phosphorus in food in the intestine and does not allow it to be absorbed. Phosphorus binders are usually used when phosphorus levels are over 1.9 mmol/L/l (US: 6 mg/dl) according to feline renal specialists; and once you start using binders, the goal is to  get phosphorus down to a level of around 1.3 mmol/L/l (US: 4 mg/dl). To be effective, phosphorus binders should be given before or with food. You should start to see a difference in phosphorus levels around 7-10 days after starting binders. There are instructions on how to give binders below.

Dr David Polzin of the College of Veterinary Medicine of St Paul's in Minnesota states that phosphorus binders should be begun "when serum phosphorus concentration exceeds 6.0 mg/dl."

Dr Jonathan Elliott of the Royal Veterinary College states on page 14 that "the goal should be to keep the serum phosphorus concentration at the lower end of the reference range".

Phosphatemia management in the treatment of chronic renal disease: a round table discussion (2006) states "practitioners need to realise that a phosphate in the normal range could still be abnormal in renal patients".

Feline Phosphorus Management is a list for those trying to control phosphorus levels in their CRF cats.

Binder Types

There are four types of antacids that are used as phosphorus binders, two of which are aluminium-based and two of which are calcium-based. There are also some relatively new binders on the market or expected shortly. Whichever type of phosphorus binder you choose, there are potential downsides. Some British vets recommend sucralfate as a phosphorus binder, but it really is not the best choice.

The types available are: 

Aluminium-Based Binders

aluminium hydroxide

aluminium magnesium hydroxide

Calcium-Based Binders

calcium acetate

calcium carbonate

Other Types of Binder

Renagel

Ipakitine/Epakitin

Lanthanum Carbonate (Renalzin, Fosrenol and Renalan)

Aluminium-Based Binders

You may have read that there is a risk of aluminium toxicity from the aluminium in aluminium hydroxide medications but this refers to human patients on dialysis (because aluminium is used in the dialysis process) which is not a concern for cats; plus it takes years before it becomes a problem for humans, so all in all it is not something you need to worry about. 

Aluminium Hydroxide 

Alumininium hydroxide medications are more potent phosphorus binders than the calcium antacids, but the calcium antacids may be better tolerated from a taste perspective. Many vets seem reluctant to prescribe aluminium-based binders because they think cats hate the taste, or, if they do prescribe them, they then prescribe AlterNagel, which is peppermint-flavoured, which most cats hate, so it becomes a self-fulfilling prophecy. I recommend instead that you look into buying aluminium hydroxide binders which are tasteless and odourless (see Obtaining Supplies Cheaply). and which most cats do not seem to notice in their food. Contrary to what some vets and pharmacists seem to believe, you do not need a prescription to buy these products.

Aluminium Magnesium Hydroxide

Some aluminium-based binders, such as Maalox, Mylanta, Milk of Magnesia or Aludrox, also contain magnesium. Binders containing magnesium are not suitable for CRF cats because they can cause high magnesium levels in the blood, which in turn can sometimes cause urinary tract problems such as stones in some cats. 

Finding Aluminium-Based Phosphorus Binders

Information on the various brands of aluminium-based phosphorus binders can be found in Obtaining Supplies Cheaply, including links to mail order suppliers who can ship odourless and tasteless phosphorus binders to UK, USA and Canada.

Dosage

Naturally you must seek your vet's advice on the most suitable dosage for your cat; but generally speaking, the appropriate dosage for aluminium hydroxide based binders is as follows:

 

Current Phosphorus Level: International Values	Current Phosphorus Level: US Values	Amount of Binder to Give
Between 1.3 and 1.9 mmol/L*	Between 4.0 and 6.00 mg/dl*	25 mg per lb (0.5kg) of cat per day, divided and given with food 2-3 times a day.*
Between 1.9 and 2.6 mmol/L	Between 6.0 and 8.0 mg/dl	50 mg per lb (0.5kg) of cat per day, divided and given with food 2-3 times a day.
Over 2.6 mmol/L	Over 8.00 mg/dl	100 mg per lb (0.5kg) of cat per day, divided and given with food 2-3 times a day.

*Not everybody chooses to start binders if phosphorus levels are in this range - most people only start binders once phosphorus levels are over 1.3 (US: 6.0). However, if your cat has previously had high phosphorus levels which you have reduced with binders, you will probably need to continue to give binders, either at this dosage or even higher, otherwise your cat's values will probably rise over 1.3 (US: 6.0) again.

Aluminium hydroxide is a safe product, so it does not have to be measured too precisely, but as a rough guide, if you are using powdered aluminium hydroxide, such as the Spectrum brand sold by Goolricks, a quarter of a teaspoon of powder contains approximately 300mg of aluminium hydroxide. If you are using a liquid type of binder, as a guide, a teaspoon of Alternagel contains approximately 600mg of aluminium hydroxide.

Phosphorus binders must be given with food so they can bind with the phosphorus in it. For tinned food, if you are using tablets, you can simply crush them up and add them to the food; while capsules can be opened and the tasteless contents mixed with the food. One retailer recommends adding a teaspoon of water to tinned food and letting it stand for ten minutes before serving in order to let the binder mix thoroughly. If you are using dry food, you may wish to try putting the food in a freezer bag together with the crushed binder and leave them to mingle overnight. 

It does not matter if your non-CRF cats eat food mixed with phosphorus binders, though obviously you should try to give them some food free of binders too, particularly kittens.

Cautions

Sometimes phosphorus binders may cause constipation, so watch for this when you first start them.

Phosphorus binders should be given two hours apart from Baytril (an antibiotic), Pepcid (famotidine) or ACE inhibitors, because they may interfere with the absorbtion of these treatments, which would make them less effective.

Medline Plus mentions that Vitamin C may interact adversely with products containing aluminium, such as phosphorus binders.

Phosphorus binders should ideally be given separately from iron, because the binders may reduce the absorption of the iron. Drugstore has some information about this interaction.

Binders Containing Calcium

Using something that contains calcium as either a dietary supplement or phosphorus binder can cause too much calcium (hypercalcaemia). These binders are also not as effective as binders containing aluminium hydroxide. If you are using any type of calcium antacid as a phosphorus binder, frequent monitoring of blood calcium levels is essential.

Hypercalcaemia in cats (2001), a paper by Dr Chew presented to the World Small Animal Veterinary Association World Congress 2001   mentions that using calcium-based binders may cause hypercalcaemia.

Calcium Acetate

The calcium acetates (PhosLo) bind about three times as much phosphorus as calcium carbonate (Tums). Therefore, one of the calcium acetates is probably a better choice as a phosphorus binder than the calcium carbonate.

Calcium Carbonate

Apparently the risk of hypercalcaemia is lower with the calcium carbonates than with the calcium acetates, but still exists.

A new product called Ipakitine (or Epakitin in the USA) has recently entered the European market. This is a combination of a calcium carbonate based phosphorus binder and an oral adsorbent; see the Ipakitine/Epakitin section below for more information.

Other Binders

Renagel and Renvela

As the What Do All Those Test Results Mean? page mentions, high calcium levels are not normally a problem unless ionised calcium is also high.

Since phosphorus and calcium levels within the body are closely related, aluminium-based phosphorus binders as described above may help to reduce high calcium levels. Conversely, if your cat's phosphorus levels are below 1.9 mmol/L (US: 6 mg/dl) and you are using phosphorus binders, ask your vet about reducing the amount of binder which you give.

Keeping your cat properly hydrated can also reduce calcium levels; you may need to use saline solution rather than Lactated Ringers Solution since saline solution has no added calcium, but unfortunately saline solution can sting when administered sub-cutaneously. Alternatively, Normosol-R might be suitable.

Feeding the cat a prescription CRF diet may also help. If your cat refuses to eat this, increased fibre in the diet may help to reduce calcium levels by binding with the calcium. One food that may help with this is Hill's W/D, since this has added fibre.

On the subject of prescription CRF diets, on 6 March 2006 Royal Canin began recalling its renal LP food sold in pouches in the USA because of an excessive amount of Vitamin D in the food. This has apparently caused hypercalcaemia in four cats to date. You can read more about this problem on the Which Foods to Feed page.

Slippery Elm Bark also contains calcium, so it is probably safer not to use it if your cat has hypercalcaemia.

Some people have found that using lactulose to control constipation has led to hypercalcaemia in their cats. You may therefore wish to avoid this treatment if your cat already has hypercalcaemia, and consider alternative treatments if your cat has developed hypercalcaemia since beginning lactulose. See above for more information on this problem and for alternative treatments for constipation.

Corticosteroids such as prednisolone may sometimes be used to control high calcium levels (see steroids).

Although it is fairly rare, high calcium levels may be caused by cancer, so if the cause of your cat's hypercalcaemia is unknown, it is worth asking your vet to test for cancer.

Controlling Secondary Hyperparathyroidism

Phosphorus Control

In order to reduce the risks of secondary hyperparathyroidism, the first line of attack is to feed your CRF cat a diet low in phosphorus. If diet alone does not control the high phosphorus levels, you may need to use phosphorus binders as well.

For many cats, phosphorus control will be enough to avoid secondary hyperparathyroidism - in one study, Survival of cats with naturally occurring chronic renal failure: effect of dietary management (2000) Elliott J, Rawlings JM, Markwell PJ, Barber PJ Journal of Small Animal Practice 41(6) pp235-242, a low phosphorus diet, with added binders where necessary, prevented the rise in parathyroid hormone levels seen in the control cats who were not restricted as regards phosphorus. In fact, the cats who ate reduced phosphorus food or food with added phosphorus binders lived more than twice as long as those who did not.

Calcitriol

Calcitriol, which has been used in human CRF patients for over 20 years, is often used in the USA to control secondary hyperparathyroidism in cats, although its use is somewhat controversial - some vets believe the control of phosphorus levels alone is sufficient to control secondary hyperparathyroidism, so are opposed to the use of calcitriol in cats for this reason; whilst others are concerned that using calcitriol may raise calcium levels too much, although in practice this does not seem to be a major problem.

The use of calcitriol is not possible in the UK, because the compounding of the treatment into cat-sized dosages is not legal, so for UK readers there is little option but to focus on phosphorus control. However, for many cats this will be sufficient to avoid secondary hyperparathyroidism, except possibly for very end stage cats. 

Calcitriol is given in either oil-filled capsules or oily liquid form. The amounts needed are tiny, so the treatment has to be compounded to the correct dosage for a cat. In doses of above 6.6ng/kg it may increase calcium levels, so these should be monitored if such high dosages are to be used. US proponents of calcitriol generally propose using much lower dosages in the range of 2.5-3.5 ng/kg, which is much safer. It is best started fairly early on in CRF when these lower dosages should in theory work well.

Calcitriol will not work for cats whose phosphorus levels are already above 2.6 mmol/L (US: 8 mg/dl), and is of limited value for cats with phosphorus levels above 1.9 mmol/L (US: 6 mg/dl): for such cats, you must try to reduce the levels by using low phosphorus diets and/or phosphorus binders before considering using calcitriol. 

Benefits of calcitriol therapy and serum phosphorus control in cats and dogs with chronic renal failure. Both are essential to prevent or suppress toxic hyperparathyroidism (1996) Nagode LA, Chew DJ, Podell M Veterinary Clinics of North American Small Animal Practice 26 pp1293-1330 discusses the important of controlling secondary hyperparathyroidism in cats and the role of calcitriol in doing so.

In Current guidelines for managing feline renal failure (2001) Polzin D, Presentation to the World Small Animal Veterinary Association World Congress, Dr Polzin  states that the above study was not scientifically controlled and that further studies will be necessary before it can be determined how effective Calcitriol is for CRF (such studies are currently in progress, see a report on one such study immediately below).

Clinical benefit of calcitriol on feline chronic renal failure (2005) is a report by the Morris Feline Foundation on Dr Polzin's latest study into the use of Calcitriol in cats with CRF. Dr Polzin found that in cats with early stage CRF, Calcitriol did not appear to improve appetite, physical activity or pet-human interaction, and did not appear to alter the course of the CRF in any way. The researchers recommend against using it for this reason and because of the cost, but also state that a follow-up study to monitor the effects of Calcitriol in the longer term would be appropriate.

Calcitriol Reference Pages - detailed information on Calcitriol usage from Dr Nagode and Dr Chew of Ohio State University.

Mar Vista Vet has more information on calcitriol.

Island Pharmacy is very experienced in compounding calcitriol.

Calcitriol List - a list devoted to discussing the use of calcitriol.

Sensipar

Sensipar (cinacalcet HCl) was approved by the USA Food and Drug Administration in March 2004 for the treatment of secondary hyperparathyroidism in humans. It can also be used to treat hypercalcaemia (high calcium) caused by parathyroid cancer. Sensipar works by lowering calcium levels, so should not be used in patients with low calcium. It has not been used to treat cats with secondary hyperparathyroidism as yet. Since Sensipar is a new treatment, it is likely to be very expensive.

Amgen - an article by the manufacturers of Sensipar.

Stimulation of Red Blood Cell Production

Anaemia

Although one 2002 study (Prevalence of systolic hypertension in  cats with chronic renal failure at initial evaluation, Syme HM, Barber PJ, Markwell PJ, Elliott J, Journal of the American Veterinary Medical Association 220 pp1799-804) indicated an incidence rate of high blood pressure of only 20%, it must be remembered that this only applies to cats at initial diagnosis. In practice, it appears that at least one third of CRF cats have high blood pressure, but, since the risk of high blood pressure developing increases as the CRF worsens, some estimates actually put the incidence of high blood pressure as high as two thirds.

Whatever the incidence rate, high blood pressure must be treated if it is present because it can have serious effects, such as blindness through retinal detachment and seizures. Unfortunately high blood pressure is often known as the silent killer because it is not usually apparent. Please check the Symptoms section for possible subtle signs you might be able to detect; but the ideal preventative measure is for your vet to monitor your cat's blood pressure regularly with proper equipment if possible. 

For cats, hypertension is usually considered to be present when systolic pressure is over 145 mmHg (Doppler machines only measure systolic pressure). Many US vets start treatment when systolic pressure is over 160mmHg. See the What Do All Those Test Results Mean? page for more information on when to start treating hypertension. The goal is a blood pressure reading between 120 and 149.

High blood pressure is easily controlled in most cases by means of medication. The usual treatment is a drug called amlodipine (Norvasc or Istin), a heart medication in the calcium channel blocker family. The usual dose for cats is 0.625 mg per day but you should be guided by your vet; some cats need double this dose. It can take up to a week for amlodipine to work, though you may see results more quickly. Your vet should check blood pressure one week after starting Norvasc.

If your vet does not have the necessary equipment to check blood pressure, but strongly suspects that your cat has hypertension, it might be worth trying amlodipine and seeing if your cat improves. Generally speaking, as mentioned by Veterinary Partner, amlodipine is a pretty safe drug and is unlikely to cause the opposite problem of hypotension (low blood pressure) even in a cat whose blood pressure is not overly elevated.

It can be hard to break Norvasc into cat-sized doses, so the Tips on Medicating Your Cat page has information on how to do this. Generic amlodipine recently became available in the USA, but these pills are even smaller than brand name Norvasc, so you may find that overall there is no advantage because you waste more of the lower priced pills.

I do not recommend using compounded versions of amlodipine, because some people have found that these have not controlled blood pressure effectively in their cats. If you use a compounded amlodipine suspension, you should keep it in the fridge and discard it after 14 days.

Possible side effects of Norvasc include constipation and, rarely, dental problems (gingivitis) or an increased heart rate. Some cats may become a bit lethargic when first starting Norvasc, but this should wear off as their bodies get used to the medication - most cats eventually seem brighter once their blood pressure is under control. Any reductions in dosage should be made gradually, to give the cat's body time to get used to the lower dose.

If you are using histamine H2 antagonists to control stomach acid, you should know that cimetidine (Tagamet) may increase the effects of Norvasc (thereby possibly reducing blood pressure too far), so it would probably be safer to use Pepcid AC instead. Plumb's Veterinary Drug Handbook mentions that cyproheptadine, an appetite stimulant commonly used in CRF cats, may also have calcium channel blocking effects and cause low blood pressure: there is a risk that this in combination with Norvasc  could reduce blood pressure too far, so it is probably safer not to use these two drugs together. Cosequin, used to treat arthritis, may raise blood pressure, so speak to your vet about whether to continue using it if your cat has hypertension.

Recent research (Feline hypertension: diagnosis and management (2002)  Elliott J, 27th World Small Animal Veterinary Association Congress 2002) indicates that treating hypertension with Norvasc sometimes reduces potassium levels, so you should ensure potassium levels are monitored and supplementation begun if necessary.

The University of Zürich Institute for Veterinary Pharmacology and Toxicology warns (in German) that cats taking calcium channel blockers such as  Norvasc should not use Cerenia (maropitant).

Even if your cat's retinas detach because of high blood pressure, if treatment with Norvasc is started quickly enough (usually within three days of detachment), there is an approximately 50:50 chance of the retinas re-attaching and your cat regaining some sight. Even if you do not start Norvasc immediately, there is still hope: I know of one CRF cat who went blind but regained his sight, even though treatment was not begun for some weeks. If you can see a veterinary opthalmologist, s/he may be able to suggest other measures in addition to the use of Norvasc to increase the chances of the retinas re-attaching; but many people just use Norvasc with the help of their general vet and see an improvement in their cat's vision. If your cat does go blind and remains so, do not despair, cats cope far better with blindness than humans do, and I would not consider blindness in itself to be grounds for euthanasia. Vision loss need not affect pets' quality of life is an article from the University of Illinois at Urbana-Champaign College of Veterinary Medicine with tips for helping your cat cope with blindness.

Some vets prefer to use heart medications known as ACE inhibitors, which include enalapril (Enacard) and benazepril (Fortekor/Lotensin) to treat high blood pressure, but these are far less likely than Norvasc to reverse blindness caused by high blood pressure; and they are also more likely to cause increases in creatinine levels when first begun. However, for really severe cases of hypertension which do not respond to Norvasc alone, it may occasionally be necessary to give ACE inhibitors in addition to the Norvasc. But in most cases, you should try Norvasc by itself first.

In Chronic renal failure in the cat (2006) Sparkes AH Presentation to the World Small Animal Veterinary Association World Congress, Dr Sparkes states "in cats monotherapy with amlodipine (a calcium channel blocker) is generally regarded as the treatment of choice for systemic hypertension".

Management of systemic hypertension in cats (2001) Atkins C World Small Animal Veterinary Association Congress 2001 discusses why Norvasc is the drug of choice for cats with hypertension.

Hypertension in cats and dogs (2002) Stepien RL is a presentation to the Waltham/OSU Symposium: Small Animal Cardiology 2002. It mentions that amlodipine "is the current antihypertensive medication of choice for cats", according to a report from the Hypertension Consensus Panel, American College of Veterinary Internal Medicine entitled "Current recommendations for diagnosis and management of hypertension in cats and dogs". Dallas, TX, 20th Annual Veterinary Medical Forum, 2002.

Effects of the calcium channel antagonist amlodipine in cats with surgically induced hypertensive renal insufficiency (2002) Mathur S, Syme H, Brown CA, Elliot J, Moore PA, Newell MA, Munday JS, Cartier LM, Sheldon SE & Brown SA American Journal of Veterinary Research 63 pp833-9 indicates that Norvasc has an anti-hypertensive effect in cats with renal failure and hypertension, which may improve the prognosis for such cats. (Note: the cats in the study did not have naturally occurring CRF).

Treatment of systemic hypertension in cats with amlodipine besylate (1997) Henik RA, Snyder PS & Volk LM Journal of the American Animal Hospital Association 33 (3) pp226-234 indicates that amlodipine appears to be a safe and effective treatment for hypertension in cats.

Feline hypertension:clinical features and therapeutic strategies (2004) Bright JM Presentation to the World Small Animal Veterinary Association World Congress 2004 discusses using amlodipine in conjunction with enalapril or benazepril for cats who do not respond to amlodipine alone.

Feline hypertension: diagnosis and management (2002)  Elliott J, Presentation to the 27th World Small Animal Veterinary Association Congress 2002 also discusses the use of ACE inhibitors in addition to amlodipine in cats who do not respond to amlodipine alone, but recommends checking bloodwork if ACE inhibitors are added, since these drugs may cause an increase in creatinine levels.

Newman Veterinary - includes pictures of blood pressure monitors.

Long Beach Animal Hospital - general information.

Centennial Valley Animal Hospital - general information.

Use of ACE Inhibitors: Benazepril (Fortekor or Lotensin) or Enalapril (Enacard)

What is Benazepril?

Benazepril is commonly used to treat heart disease, particularly in dogs. Benazepril is an ACE (angiotensin-converting-enzyme) inhibitor, i.e. a drug which prevents the conversion of a hormone called angiotensin I into another hormone called angiotensin II, the role of which is to constrict blood vessels. Thus using this type of drug means the blood vessels relax and this makes it easier for the heart to pump blood through the body. The trade names of benazepril are Fortekor (UK) and Lotensin (USA). Another member of the ACE inhibitor family is enalapril (Enacard), Mar Vista Vet has more information on enalapril. Much of what is stated below probably also applies to enalapril, although the trials discussed were conducted with benazepril.

Novartis, the manufacturer of Fortekor, has been running trials of the drug in CRF cats. As a result of data collated from these trials (which were completed in 2002 although the full data were not published until 2006), Fortekor has been licensed for the treatment of feline CRF - or, as Novartis calls it, chronic renal insufficiency (CRI) - in the UK, some parts of Europe, Canada and Australia. If you are in these countries, it is therefore highly likely that your vet will offer you this treatment at some stage; indeed, in the UK, Fortekor and prescription diets are often the only treatments offered (though if they were all that is available or suitable for CRF cats, this site would be a lot shorter than it is!). 

How Does it Work?

Fortekor works by reducing hypertension (high blood pressure), both within the kidneys and in the cat's general system. Novartis presumes the reduction in pressure-related damage within the kidneys is what causes improvement in kidney function, but does not know the exact mechanism. However, if your cat has been diagnosed with hypertension, the treatment of choice is amlodipine (Norvasc or Istin), not Fortekor.

According to Novartis, giving Fortekor to cats with normal blood pressure (not all CRF cats have high blood pressure) does not appear to have any adverse effects, though Novartis does recommend monitoring blood pressure while a cat is on Fortekor. As mentioned in the Symptoms section, not many UK vets have blood pressure testing equipment but Novartis is encouraging vets to invest in this equipment, which could be helpful for CRF cats, even those not on Fortekor.  

Clinical Trials of Fortekor

Fortekor was tested on 100 cats with elevated creatinine levels, low urine specific gravity and no other diseases, such as heart problems, at commencement of the trial. The cats were all pet cats, patients of several veterinary practices around Europe, and were also fed a CRF prescription diet. Novartis claims that Fortekor improves quality of life, although I do not know how they define or measure that.

Fortekor appears to reduce proteinuria (loss of protein in the urine, which may cause progression of CRF) through its effects on GFR (see What is CRF?) and minimises the risk of hypokalaemia (low potassium levels). Novartis further states that cats who were "severe cases" (which they define as where the urine protein/creatinine ratio is greater than 1.0, i.e. cats with severe proteinuria; this was only a small proportion of the cats in the trial) and who received Fortekor showed improved appetite and weight gain, and had an average survival time of 402 days versus 126 days for those cats being treated with prescription diet only.

As mentioned above, Novartis also claims that Fortekor is safe to treat CRF at all stages of the disease, although it should be noted that creatinine levels often rise when Fortekor is first begun.

Not all of the 200 cats originally enrolled in the trial (100 receiving Fortekor, 100 receiving a placebo) survived for the entire length of the trial, but those who did remained in the trial for the full three years. The trial was originally scheduled to run for two years, but was extended for a further year; but the data to which Novartis refers in the publicity literature only relate to the first year of the trials (apart from the figures for survival time for cats with severe CRF), partly because after a year many of the trial cats were dead. 

I find it strange that Novartis took so long to publish the full data relating to their trial. A paper, Tolerability and efficacy of benazepril in cats with chronic renal disease (2006) King JN, Gunn-Moore DA, Tasker S, Gleadhill A & Strehlau G Journal of Veterinary Internal Medicine 20(5) pp1054-1064,  was finally published in 2006. It stated that "there was no difference in renal survival time between the two groups when all 192 cats were compared" but found that benazepril does appear to reduce proteinuria in cats.

In 2002, the Evidence Panel of the American College of Internal Veterinary Medicine gave the use of ACE inhibitors in CRF a grade 3, the lowest grade available.

Fortekor is primarily excreted (85%) via the liver in cats, so does not carry the possible kidney risks associated with some other ACE inhibitors such as enalapril (excreted largely by the kidneys, which puts additional strain on them). Fortekor has not been tested in cats weighing less than 2.5kg (5 lbs).  Toxicity studies were carried out on young, healthy laboratory cats. 

One of my concerns with Fortekor is that it is not used to treat a specific concern of CRF (except, in some cases, proteinuria), whereas most treatments for CRF are used for a specific problem such as, say, stomach acid, and have measurable effects, which Fortekor does not appear to have. I am also concerned that Fortekor may be offered instead of these other proven treatments, such as phosphorus binders, sub-Qs etc., though Novartis does advocate the use of Fortekor alongside supportive treatments rather than instead of them (see Feline Good, a site sponsored by them).

Trials on larger number of cats, including cats with other CRF-related health problems such as heart disease, would be helpful, but since Fortekor is already approved in Europe, Novartis has no incentive to run such trials. 

Cautions

Fortekor has not been tested in cats weighing less than 2.5kg (5 lbs) so be careful if you have a small cat. 

Novartis considers that the term CRI refers to cats where bloodwork shows evidence of renal problems, whereas CRF refers to cats who are also exhibiting symptoms; however, Novartis states that Fortekor can be used at any stage of the disease, i.e. as soon as there is any evidence of decreased renal function right through to cats with very elevated urea (BUN) and creatinine levels. However, I advise caution about using Fortekor in a cat with high numbers, since the rise in creatinine levels which may occur when Fortekor is first begun might in theory be enough to push a cat over the CRF precipice. I personally would not choose to use Fortekor in a cat with creatinine over 310 (US: 3.5). Whatever your cat's numbers, you should have bloodwork run about five days after beginning to use Fortekor, and monitor blood pressure.

The use of Fortekor may also lead to an increase in potassium levels, which can be a risk in a cat who already has high levels of potassium. 

ACE inhibitors may cause lethargy, particularly when first begun. This may be a sign that blood pressure has fallen too low, which in turn may lead to an increase in creatinine levels as described above.

ACE inhibitors should be given two hours apart from phosphorus binders, because the binders may interfere with absorbtion of the ACE inhibitors.

Almost all of the research into the use of these newer products has taken place in Japan, and some of these adsorbents seem to be routinely used in Japan when treating human CRF patients; therefore, if you are in Japan, you may also be offered these treatments for your cat. However, one such treatment, Ipakitine, was developed in Germany.

Ipakitine/Epakitin

Ipakitine has been available in the UK since December 2002 and in the rest of Europe for even longer. Ipakitine was introduced into the USA in 2005, under the slightly different name of Epakitin, and is now commonly offered by US vets.

What is Ipakitine

Ipakitine is partly a phosphorus binder, containing calcium carbonate. However, it also contains an adsorbent called chitosan, which is said to help with uraemic toxins.

How Does Ipakitine Work?

Please see What Do All Those Test Results Mean? and Treatments for more information about calcium-based phosphorus binders.

Chitosan is a polysaccharide similar to cellulose and is obtained from the shells of crustaceans (shell fish such as crabs). 

When protein is eaten and digested, an amino acid in the food called tryptophan is converted into indoxyl, which in turn is converted by the body into indoxyl sulphate, a type of uraemic toxin. Chitosan is said to bind with the indoxyl, so it cannot be converted to indoxyl sulphate, thus reducing toxin levels, which helps the cat to feel better. Chitosan is also said by the manufacturer to help reduce BUN/urea levels, and indirectly to reduce creatinine levels. The manufacturer appears to be basing these claims largely on the results of human trials (see clinical trials).

Chitosan may also reduce cholesterol levels, but high cholesterol levels are not normally a concern for cats as they are for humans; it is also said to increase levels of haemoglobin. 

When and How is Ipakitine Used

Ipakitine comes in powder form, and is apparently tasteless. It is sprinkled on the cat’s food for a period of up to six months, although it may be used for longer if your vet agrees. Dosage is weight-related, and phosphorus levels do not appear to be taken into account when determining how much to give.

From my discussions with German users of Ipakitine, it seems to be commonly prescribed in Germany for cats who refuse to eat a prescription diet; I presume this is both for its phosphorus-binding effects and for its toxin-binding effects (since higher levels of protein in the diet may cause increased BUN/urea levels).

In the USA, Epakitin is marketed as both a "nutraceutical" and a "nutritional supplement". In the marketing literature, emphasis seems to be placed on its role as a phosphorus binder, but many vets seem to sell it to clients whose cats do not have elevated phosphorus levels, so they are presumably advocating it for its chitosan-related effects.

My own vet in the UK has seen falls in creatinine and urea in some cats when using Ipakitine and no other treatments. I would be happy to try it myself in a CRF cat who did not have very high phosphorus levels, and assuming none of the cautions below applied.

Ipakitine is very expensive in the USA, so if you really want to try it, you might want to consider buying it online (see below). Or you could just skip it and opt for cheaper aluminium hydroxide-based phosphorus binders instead, which are available over the counter without prescription.

For a cat with higher phosphorus levels (over 2.25 international, 7 USA), I personally would opt to use an aluminium hydroxide-based phosphorus binder instead of Ipakitine in any event. Even for cats with lower phosphorus levels, if the cat's phosphorus multiplied by total calcium is higher than 70, the cat is at risk of tissue calcification (see secondary hyperparathyroidism). In such a case, again I would opt for using an aluminium hydroxide-based phosphorus binder, in order to get the phosphorus levels under control as quickly as possible.

Clinical Trials

Epakitin: new arms in renal protection (2005), a brochure from the manufacturers of Ipakitine, cites unpublished data from Dr Scott A Brown at the University of Georgia which indicated that Ipakitine/Epakitin reduced phosphorus levels in the CRF cats in his study. Dr Brown has told me this was a small randomised placebo-controlled study of 12 cats. He did not find that Ipakitine reduced BUN or creatinine levels in this study.

Effects of a dietary chitosan and calcium supplement on calcium and phosphorus metabolism in cats (2004) Wagner E, Schwendenwein I, Zentek J Berliner und Muenchener tieraerztliche Wochenschrift 117 pp310-315 found that Ipakitine reduced phosphorus levels in the CRF cats in the trial.

Effect of iron (III) chitosan intake on the reduction of serum phosphorus levels in rats (2000) Baxter J, Shimizu F, Takiguchi Y, Wada M, Yamaguchi T The Journal of Pharmacy and Pharmacology 52 pp863-74 indicated that a compound of iron and chitosan might be a more effective phosphorus binder than the commonly used binders. This is, however, not the same product as Ipakitine, and cats are not rats.

Effect of chitosan on renal function in patients with chronic renal failure (1997) Jing SB, Li L, Ji D, Takiguchi Y, Yamaguchi T The Journal of Pharmacy and  Pharmacology 49 pp721-23 describes a human trial into the effects of chitosan on 80 patients undergoing long term haemodialyis in Japan. The patients' cholesterol levels reduced and their haemoglobin levels increased, and their appetites improved; reductions in BUN/urea and creatinine were also seen after four weeks of treatment. 

Cautions

Products containing calcium are not normally suitable for cats with high levels of calcium (hypercalcaemia). The risk of hypercalcaemia is lower with calcium carbonate-based binders (which is what Ipakitine contains) than with other calcium-based binders, but if your cat is taking Ipakitine, it would probably be wise to monitor his/her calcium levels. Ipakitine should not be used in cats taking Calcitriol.

Calcium-based phosphorus binders are not as effective as aluminium hydroxide based binders, and the type of calcium contained in Ipakitine (calcium carbonate) is the least effective type of calcium-based binder: calcium acetate type binders bind three times as much phosphorus as calcium carbonate based ones. Therefore if your cat has high phosphorus levels (over 2.25 international, 7 USA ), I personally would opt to use an aluminium hydroxide-based phosphorus binder instead of Ipakitine in any event. Even for cats with lower phosphorus levels, if the cat's phosphorus multiplied by total calcium is higher than 70, the cat is at risk of tissue calcification (see secondary hyperparathyroidism). In such a case, again I would opt for using an aluminium hydroxide-based phosphorus binder, in order to get the phosphorus levels under control as quickly as possible.

There is more information on these issues above under phosphorus binders. 

Indoxyl sulphate is only one of a number of uraemic toxins, so Ipakitine alone may not be sufficient to deal with problems such as stomach acid.

Websites

Vetoquinol USA is the manufacturer’s US website.

The Caledonian Cat Clinic in Scotland sells Ipakitine online at £6.59 (approximately US$13) for 50g plus P&P of £3.95 (free for orders over £45 excluding VAT), or £17.70 for 150g. They will ship to other countries.

Best Pet Pharmacy sells Ipakitine for £7.20 for 50g.

Vetscriptions sells Ipakitine for £5.99 for 50g.

Medi-Vet sells Epakitin for US$18.89 (50g), US$47.89 (150g) or US$68.89 (300g).

Entirely Pets sells Epakitin for US$17.99 (50g), US$46.99 (150g) or US$67.99 (300g).

Kremezin (AST-120)

Kremezin (AST-120) is an oral adsorbent which has been used to treat human CRF patients in Japan since 1991, and which is sometimes prescribed for CRF cats in that country. It has been tested on humans (these trials continue) and on rats with surgically-induced renal failure, but not on cats as far as I am aware, although a feline version of Kremezin is on sale in Japan. However, I have heard from a couple of Japanese people who have used it on their cats without any problems.

Kremezin was developed by Kureha Chemical Industries and marketed in Japan for the treatment of feline CRF by Sankyo Lifetech under the trade name of Covalzin. This part of Sankyo Lifetech's business was sold to Novartis in 2007, which presumably plans to introduct Covalzin into Western markets. The human version of Kremezin is not expected to be commercially available in the USA until 2009 or later, although JCN Network reports that Kureha Chemical Industries introduced Kremezin in South Korea in 2005. It is possible that Novartis will try to introduce the feline version before the human version is approved.

A multi-center, randomized, double-blind, placebo-controlled, dose-ranging study of AST-120 (Kremezin) in patients with moderate to severe CKD (2006) Schulman G, Agarwal R, Acharya M, Berl T, Blumenthal S, Kopyt N American Journal of Kidney Disease 47(4) pp565-577 is a study of human CRF patients in the USA. The study found that AST-120 did not reduce creatinine levels, but it did appear to help the patients feel better ("significant improvements in malaise were observed").

Combination therapy with benazepril and oral adsorbent ameliorates progressive renal fibrosis in uraemic rats (2002) Aoyama I, Shimokata K, Niwa T Nephron 90 pp 297-312 - this study of a very small group of rats with surgically-induced renal failure indicated that rats treated with both medications did better than rats treated with neither or with only the benazepril.

Indoxyl sulfate and progression of renal failure: effects of a low protein diet and oral sorbent on indoxyl sylfate production in uremic rats and undialysed uremic patients (1997) Niwa T, Tsukushi S, Ise M, Miyazaki T, Tsubakihara Y, Owada A, Shiigai T Mineral and Electrolyte Metabolism 23 pp179-184 suggests that the use of Kremezin may reduce levels of indoxyl sulphate, as does a low protein diet. 

Azodyl and Other Probiotics

Azodyl is essentially a type of probiotic. Probiotics are commonly used to re-balance the bacteria in the gut, particularly after using antibiotics - there is more about them in the antibiotics section.

Azodyl contains strains of Streptococcus thermophilus, Lactobacillus acidophilus and Bifidobacterium longum, along with a prebiotic, psyllium. The manufacturers of Azodyl claim that their strains of these bacteria have a particularly high affinity for some of the major uraemic toxins found in CRF. Azodyl is intended to bind with and reduce the levels of these uraemic toxins in CRF cats, hence its name, which is a play on azotaemia and dialysis.

Some of the urea produced by the body is excreted via the large intestine, with the remainder being excreted via the kidneys. In CRF, the kidneys may struggle to cope with excreting urea, leading to a build up of toxins in the cat's body. The use of fermentable fibre  in CRF is aimed at diverting more of the urea to the large intestine/faecal route, thus relieving the workload imposed on the kidneys. Azodyl appears to be intended to work not only as a probiotic, but also in a similar (but not identical) way to fermentable fibre, by binding with uraemic toxins in the large intestine, thus reducing the workload on the kidneys (Kibow Biotech call this "enteric dialysis"); it also seems to have some similarities to oral adsorbents such as Ipakitine/Epakitin (also manufacturered by Vetoquinol), which also bind with uraemic toxins.

Azodyl was created by Kibow Biotech, and was introduced to the US market in July 2006 by Vetoquinol, the manufacturers of Ipakitine/Epakitin. These companies are currently discussing Vetoquinol purchasing the manufacturing and marketing rights for Azodyl for the rest of the world, but until that happens Azodyl is already available in some other markets under the name of Kibow Biotics.

Using Azodyl

I have heard reports from a number of people who have used Azodyl. Most people seem to think it has helped their cats, though some people find that it can make a cat vomit, and some people think it did not make any difference. It may take up to a month before you see any benefit from using Azodyl, though apparently some people see results (usually in the form of better appetite) within two weeks.

Giving Azodyl to cats may be problematic. Firstly, the required dosage is quite high: a cat weighing 5-9 lbs would require three capsules a day according to a table provided by Kibow Biotech which shows dosage requirements according to weight.

Secondly, Azodyl is enteric-coated, which means it is intended to release its contents in the intestines rather than the stomach. For this reason the capsules are intended to be given whole; however, they are a size 1 capsule, which is rather large for many cats; this may be one reason why some cats throw up the entire capsule, sometimes several hours after it has been given. Some people open the capsules and sprinkle the contents on food, though there is no guarantee that the contents will reach the intestines as is intended if you do this. If you do opt for this method of administration, the manufacturers advise doubling the dose. They also advise mixing the contents of the opened capsule with a small amount of tinned food, and feeding this one hour prior to feeding a full meal, in order to give the probiotics the right environment to work properly. 

Azodyl should not be given at the same time as antibiotics; separate them by 2-3 hours.

Azodyl should be kept in the fridge, otherwise the bacteria may die. They can probably survive in normal weather, so if you leave Azodyl out overnight there is probably no cause for concern, but it is best to have Azodyl shipped chilled.

Since Azodyl is classified as a dietary or nutritional supplement, clinical trials are not required by the American Food & Drug Administration. However, Probiotic amelioration of azotaemia in 5/6th nephrectomised Sprague-Dawley rats (2005) Ranganathan N, Patel B, Ranganathan P, Marczely J, Dheer R, Chordia T, Dunn SR, Friedman EA Scientific World Journal 24;5 pp652-60 is a study on rats who were treated with probiotics, including probiotics provided by Kibow Biotech (which did not appear to be identical to Azodyl). The study seemed to show that Bacillus pasteurii and Sporolac (Lactobacillus sporogenes) were particularly effective. Sporolac is produced by Sankyo Co Ltd in India, where it is commonly used in farm animals. I have not been able to find a source for it in Europe or North America. 

The Veterinary Information Network is running a trial into Azodyl and is seeking participants (who must apply via their vet). This page explains the criteria for taking part. The manufacturer intends that Azodyl should be given whole, which as mentioned above can be difficult to do because the capsules are so large. The study is investigating whether opening the capsules and sprinkling them on the cat's food will affect the product's effectiveness.

Kibow Biotech explains more about the reasoning behind Azodyl.

Kibow Biotech reports in its studies into the use of probiotics.

Kibow Biotech reports on a trial conducted at a veterinary practice in California.

Azodyl - a website from Vetoquinol.

Sources

If you buy Azodyl online, it must be shipped cold, otherwise the bacteria can die.

California Veterinary Supply sells 60 Azodyl capsules for US$25.99 plus shipping. They will ship to UK and Canada.

Entirely Pets sells 60 Azodyl capsules for US$29.99 plus shipping.

Thriving Pets sells 60 Azodyl capsules for US$27.98, plus US$25 for cold-packed two day shipping (the shipping cost is the same for up to 180 capsules).

Amazon sells 60 Azodyl capsules for US$23.98, plus US$6.13 shipping, though it is not clear if this covers chilled shipping.

Your Shopping Network sells 60 Kibow Probiotic capsules for US$40 plus shipping.

Astro's Nitrogen Scrub

The manufacturer of Astro's CRF Oil also makes a product called Astro's Nitrogen Scrub, although it is not mentioned on the manufacturer's website. This product is made of an acacia gum powder and is intended to act as a kind of probiotic, although confusingly it is supposed to be mixed with a probiotic such as kefir, so I'm not too sure how you are supposed to know if it is the Astro product or the probiotic generally which is working. Some people simply mix it into food though. I don't know many people who have used the scrub, but one person has used it for a year and thinks that it probably has helped overall.

Anti-Oxidants

Anti-oxidants mop up free radicals in the body, which are associated with aging and disease. Co-enzyme Q10 (CoQ10) is an anti-oxidant that is used by the body in energy production. It is important for heart function, and is sometimes used in people and cats with heart disease for that reason (see Related Diseases).

A recent human trial, Randomised double-blind placebo-contolled trial of co-enzyme Q10 in patients with end stage renal failure (this link often doesn't work properly, you may need to search for this study on this site) (2003) Singh R, Kumar A, Niaz MA, Singh RG, Gujrati S, Singh VP, Singh M, Singh UP, Taneja C, Rastog SS Journal of Nutritional and Environmental Medicine 13 (1) pp 13-22, indicated that CoQ10 may reduce creatinine and BUN levels in some patients.

I am not aware of any studies of using CoQ10 in CRF cats, but generally speaking CoQ10 is normally considered to be a safe supplement with few side effects, though please do not give it without your vet's approval. It may lower blood glucose levels, so extra care should be taken if you and your vet decide to use it in a diabetic cat.

CoQ10 is available from health food stores. If you decide to use it, it should be given with fat or oil, so it is normally given with food. A possible starting level would be 10mg for a 15 lb cat a day, though some people give higher amounts (Holisticat recommends 30mg a day for cats with heart disease).

If you do decide to try CoQ10 with your vet's agreement, please do not stop using it suddenly. There have been several cases of humans and one cat with heart disease who were using CoQ10 relapsing after it was stopped suddenly. This might not be such a risk with cats with CRF rather than heart disease, but if you do decide to stop using it, it would probably be safer to do so gradually.

Oxidative stress and antioxidant therapy in cats with renal failure is a study currently (2007/8) being undertaken by Dr CB Webb at Colorado State University.

Long-term coenzyme Q10 therapy: a major advance in the management of resistant myocardial failure (1985) Mortensen SA, Vadhanavikit S, Baandrup U, Folkers K Drugs under Experimental and Clinical Research 11(8) pp581-93 found that "preliminary CoQ10 withdrawal results showed severe clinical relapse with subsequent improvement on CoQ10 reinstatement."

University of Maryland Medical Center is a human site with information about CoQ10.

The Mayo Clinic reports that "there is initial data from one small trial [in humans] to support the use of CoQ10 in the treatment of kidney failure. More research is needed before a recommendation can be made."

Astro's CRF Oil

Since early January 2007, I have received several enquiries about a new product called Astro's CRF Oil, which was created by a human doctor to treat his own CRF cat. This product is basically a combination of essential fatty acids and CoQ10 but in a concentrated formula.

Astro's CRF Oil contains approximately 565mg EPA, 340 mg DHA, 15 mg Ubiquinon (CoQ10) and natural Vitamin E  (D-tocopherol) 200 IU per 1.5ml dose. It is claimed that combining these ingredients creates a synergistic effect. The intention is for the product to have a strong anti-inflammatory effect, which it is hoped will help the kidneys.

The manufacturer states that the product has been tested on a number of CRF cats, but no details appear to be available. The product's website states that using this product may enable you to stop other treatments such as sub-Qs, but I cannot see why an anti-inflammatory product might help prevent dehydration. I certainly would not recommend stopping any of your cat's current treatments, particularly sub-Qs, without your vet's knowledge and approval.

Essential fatty acids do have an anti-inflammatory effect. However, one kidney specialist vet has informed me that oversupplementation can throw off the correct ratio of Omega-3s to Omega-6s, and might be detrimental in some cases. I do know a number of people who have ordered the product, however, and I will report back on their experiences in due course. At the moment (January 2008), the feedback I have received is favourable, with people reporting that their cats seem "better", albeit in some unmeasurable way.

If you do use Astro's CRF Oil, please see the advice about not abruptly stopping products containing CoQ10 here.

Please see the Food Composition and Nutritional Requirements page for more information on essential fatty acids and Astro's CRF Oil, including a treatment protocol for essential fatty acids.

Kidney Transplants

A Treatment, Not a Cure

Some people are surprised to find kidney transplants listed as a treatment, but that is exactly what they are - a form of treatment, not a cure.

One centre has stated that the average survival time for a cat receiving a kidney at its facility is only 18 months; whilst The Animal Medical Center in New York has stated that 25% of cats who undergo transplants there do not even survive the initial operation of receiving the kidney, and only 60% survive one year. Even at one of the most longstanding centres, The University of California at Davis, 20-25% of cats die in the year following the transplant.

Problems arise for a number of reasons. Firstly, this is major surgery, and by definition it is being performed on seriously sick cats. Secondly, immuno-suppressive drugs (usually cyclosporine), which stop the body rejecting the new kidney as a foreign body, are required. These must be given religiously at set times (usually every twelve hours), but even so, they may not work for every cat, and then the new kidney is rejected by the cat's body and ceases to work. Since these drugs suppress the immune system, transplant recipients are also vulnerable to infections, which may damage the new kidney.

Unfortunately these anti-rejection medications also increase the chances of the cat developing cancer, with a 14% incidence rate reported in cats at one facility who survived more than one year after the transplant. 10% of cats also develop diabetes.

Because of the foregoing, as The University of California at Davis explains, "Due to all the inherent risks with transplantation, it is not considered a prophylactic procedure, and those cats that are doing well with medical management are not considered candidates for transplantation."

Transplants are also extremely expensive; the Animal Medical Centre in NYC estimates the cost at US$8000 for the initial surgery and hospitalisation, follow-up care at US$4000 in the first year and medications and check-ups at US$3000 for each further year.

Ethical Considerations

The transplanted kidney is taken from a healthy cat, who usually then goes to live with the family of the recipient. The major UK charities, Cats Protection, the RSPCA and the Feline Advisory Bureau, are opposed to kidney transplants because of the ethical issue of removing a kidney from a healthy donor cat with no benefit to that cat, a concern which I share. It is often argued that using a shelter cat "saves a life"; but in the UK, very few cats are euthanised compared to the millions in the USA; and in any event, all the US transplants I have heard about in recent years used a cat purpose-bred by the transplant facility, so no shelter cat was "saved". I also wonder what would happen should the donor cat develop CRF him/herself later in life; presumably such a cat, with only one functioning kidney, would develop end stage renal failure more quickly than a cat with two kidneys.

Both Cats Protection and the RSPCA have stated that they will not supply cats as donors, and Cats Protection have gone so far as to state that they would "support rigorous punishment measures for any individual who acquires a cat, through whatever means, to use as a donor for feline kidney transplantation".

Availability

Kidney transplants are available at a limited number of facilities in the USA and at one location in Australia. They have not yet been performed in the UK, but on 27 February 2003, the Royal College of Veterinary Surgeons (RCVS) issued guidelines for the procedure. According to the RCVS, the guidelines were published in order to ensure the highest welfare standards for both the recipient and the donor. The RCVS envisages that approved transplant centres will have to meet very strict criteria, so it is expected that it will be quite some time, perhaps even years, before it is possible to perform the procedure in the UK. They are not currently (February 2006) available in the UK.

I do find it ironic that the RCVS is prepared to permit kidney transplants when it makes so little effort to promote other, far cheaper and less invasive treatments such as sub-cutaneous fluids.

Miscellaneous

Antibiotics

Antibiotics are not an integral part of treating CRF, so if your vet prescribes them, you should ask why. Some CRF cats may need them for other reasons, such as a urinary tract infection, a kidney infection or dental problems, but they are not normally given routinely to a CRF cat. Commonly prescribed antibiotics for CRF cats include:

• Clavamox/Synulox (often used for urinary tract infections);

• Baytril (often used for kidney infections and bad urinary tract infections); and

• Antirobe (often used for dental infections).

• Convenia (new one-off injectible antibiotic)

Once you begin a course of antibiotics, it is very important that you complete the course. If you do not do so, the bacteria may regroup and cause a stronger infection which has become resistant to that antibiotic. If your cat reacts badly to an antibiotic, contact your vet and discuss changing to another type.

If you are giving antibiotics, you may need to re-balance the bacteria in your cat's gut. A small amount of natural, unflavoured yoghurt may help, but since many cats are lactose intolerant, there is a risk that this might actually make any diarrhoea caused by the antibiotics worse. You may therefore find it easier to buy a commercial product in capsule form instead. One popular probiotic brand on the Feline CRF Information list is Culturelle, which contains lactobacillus. A typical feline dose is half a capsule in the morning and half a capsule in the evening while the cat is on antibiotics, but check with your vet. An alternative brand, designed especially for pets, is Benebac, available from Revival Animal Health among others. FortiFlora is another option, available from Entirely Pets.

Consumer Lab has a report on what probiotics do and how to choose one.

Probiotics are currently being considered as a treatment for CRF in their own right; see the Azodyl section for more information.

Clavamox/Synulox (Amoxicillin and Clavulanate)

Clavamox, known as Synulox in Europe, is a combination of two drugs, amoxicillin and clavulanate, which work together to treat or prevent bacterial infections in animals. Amoxicillin is an antibiotic in the penicillin family. Clavulanate is an inhibitor of an enzyme produced by bacteria, which could render the amoxicillin inactive if the clavulanate were not present. This means Clavamox may kill bacteria which amoxicillin alone could not kill. 

Clavamox/Synulox is often prescribed for urinary tract infections in CRF cats. It tends to be the antibiotic which most UK vets prescribe routinely for many infections. I happen to like Synulox, not least because it comes in flavoured pills in the UK which Harpsie will happily eat out of my hand. But unfortunately it can cause stomach upset, vomiting and loss of appetite in some cats. Giving food before you give the antibiotic may help, but if not, contact your vet to see if you should switch to a different antibiotic, but do not simply stop giving the Calavamox/Synulox because this may make the infection return. 

Mar Vista Vet has some information about Clavamox (be sure to click on the additional link about amoxicillin).

Pet Place also has some information about Clavamox.

Baytril (Enrofloxacin)

Baytril is an extremely effective broad spectrum antibiotic (i.e. it works on a wide range of bacteria) which belongs to the fluoroquinolone family. It is particularly good for kidney infections, where it can reach bacteria deep in the kidneys which less powerful antibiotics cannot touch. It has saved Harpsie's life on several occasions.

However, like any antibiotic, Baytril has possible side effects. The most worrying one with Baytril is that it has been shown to cause retinal problems, including blindness, if given to cats in high doses. The official dose in most countries is therefore 5 mg of Baytril per kg of bodyweight of the cat per day, a dosage which has been shown to be safe. A kg is 2.2 lbs, so, for example, the maximum daily dose for a 10 lb cat is 22.5mg per day, calculated as follows:

• 10lb cat = a 4.5kg cat x 5mg per kg = 22.5mg per day.

The recommended maximum course of treatment is 30 days (although Harpsie has been on a longer course for his kidney infections with no problems). Baytril is given once daily; giving it more frequently actually reduces its effectiveness.

Baytril must not be given within two hours of products containing calcium or aluminium (such as phosphorus binders) or iron (such as Pet Tinic), because they may inhibit absorption of the Baytril.  Sucralfate must also be give separately from Baytril for the same reason.

Baytril may lower the seizure threshold, so may not be the best choice in cats with a tendency to have seizures. Although Harpsie has epilepsy, fortunately for us he has not thus far had any problems with Baytril.

Mar Vista Vet has a good overview of Baytril.

Safety and Toxicology is a report from Bayer, the manufacturer of Baytril, which includes information on the risks of blindness in cats.

Dosage and Duration of Treatment is a report from Bayer, the manufacturer of Baytril, on the recommended dosage and length of treatment. It mentions that Baytril appears to be most effective when it is given once daily.

US Food and Drug Administration has a copy of a letter sent by Bayer to American vets outlining the risks of blindness at high doses and recommending a maximum dose of 5mg per kg bodyweight per day.

Tufts University Cummings School of Veterinary Medicine - this is a summary of the situation regarding Baytril and blindness in cats by Dr Isabel Jurk, head of ophthalmology.

Enrofloxacin-associated retinal degeneration in cats (2001) Gelatt KN, van der Woerdt A, Ketring KL, Andrew SE, Brooks DE, Biros DJ, Denis HM, Cutler TJ Veterinary Ophthalmology 4 (2) pp99-106 reports on the risks of blindness and recommends adhering closely to the guidelines regarding the maximum recommended dose.

Antirobe (clindamycin)

Antirobe (clindamycin) belongs to the lincosamide family of antibiotics. It is approved for use in dogs but is used off-label for cats. Antirobe is often prescribed for dental infections because it is particularly good at killing anaerobic bacteria which are often found in the mouth.

Like most antibiotics, Antirobe may cause an upset stomach. It should be used with caution in CRF cats - the normal dosage may need to be adjusted. The manufacturers recommend that kidney and liver bloodwork should be checked if Antirobe is given for longer than 30 days.

Mar Vista Vet has some information about Antirobe.

Convenia (cefovecin)

Convenia is an injectible antibiotic in the cephalosporin class that was approved in Europe in 2006 and in USA in 2008. It is approved in the USA for the treatment of skin infections in dogs and cats and urinary tract infections in dogs. In Europe, however, it is approved for these conditions but also for the treatment of urinary tract infections in cats.

Convenia is only available as an injection. It lasts 14 days, so is very convenient, particularly for cats who hate to be pilled. Efficacy and safety of cefovecin for the treatment of urinary tract infections in cats (2008) Passmore CA, Sherington J, Stegemann MR Journal of Small Animal Practice 49(6) pp295-301 found that an injection of Convenia was as effective as a 14 day course of cephalexin.

Possible side effects include lethargy, vomiting and diarrhoea. There may also be skin irritation at the injection site. Convenia can remain in the body for up to 65 days. The European Medicines Agency recommends that Convenia should be reserved for use in animals whose conditions have not responded or are not expected to respond to other antibiotics. It has not been tested in cats with severe kidney problems.

Most people I have heard from who have used Convenia were pleased with it. My Ollie was given this for a urinary tract infection but his UTI symptoms began to return about 10 days after the shot, so we switched to Synulox, which seems to be working better for him.

Pfizer product overview sheet an overview of the US version of Convenia.

Pfizer prescribing information for the USA.

National Office of Animal Health in the UK provides contra-indications and warnings re the use of Convenia.

Drugs.com reports on the safety testing of Convenia in cats and dogs.

Flea Treatments

Many flea treatments are fairly powerful, which makes using them on a sick cat a big decision. However, fleas can make a cat uncomfortable and a severe infestation may even cause anaemia, so the problem must be addressed. 

Commercial Preparations

Over The Counter Products

Don't waste your money on over the counter treatments - they rarely work but may still have severe side effects - the US Environmental Protection Agency has investigated thousands of problems arising from the use of Hartz products, for example. In the UK, the Feline Advisory Bureau reports that there have been hundreds of cases of cats being poisoned by permethrin-based flea treatments intended for dogs.  Flea collars in particular are useless, plus they expose the cat to toxins 24/7 - not a good idea for a sick cat. Products containing essential oils should also be avoided - essential oils are toxic to cats, who lack the pathways to metabolise them.

Prescription Products

I suggest you obtain an effective treatment from the vet; if you do this, you can also take the added precaution of asking your vet if it is safe to use the product on your particular cat. The four most commonly recommended products are Frontline, Advantage, Revolution and Capstar. Use the weakest product you can that will do the trick. I have always used Frontline, and have found it very effective, but my cats only get fleas very occasionally so I have never needed to use any product on an ongoing basis.

The manufacturer of Revolution (known as Stronghold in the UK) specifically cautions against using Revolution (Stronghold) on sick cats. Bayer, the manufacturers of Advantage, offer a similar warning for its product. In Seizure disorders in dogs and cats, Dr RM Clemmons from The Neurology Service at the University of Florida's Veterinary Medical Teaching Hospital mentions that Advantage and Program "appear to lower the seizure threshold and make seizure disorders more difficult to control", so I would not use them on a cat who has had a seizure or who is ar risk of seizures.  

There is another flea treatment called Capstar. This is given in pill form and is safe enough to give to very young kittens, so you could ask your vet if it might be suitable for your CRF cat. Unfortunately it only kills existing fleas, it does not act as a preventative.

In fact, you don't necessarily have to apply flea products directly on your CRF cat: if you have other, healthy companion animals, try applying the commercial preparation you choose only to the other family animals, and use a flea comb on all the animals every day, including the CRF cat; be sure to treat your carpets too with a cat-safe preparation, since the fleas will live in them and can re-infest your cat. Eventually you should find all the animals are free of fleas, even the CRF cat. I did this using Frontline, and we did get rid of the fleas, though we do not get fleas often anyway, only about every eighteen months (yes, despite having long-haired, indoor-outdoor cats!). Because of this, I do not treat my cats month in, month out, I only treat them when they actually have fleas; if you live in a relatively flea-free area, you may wish to consider this approach.

However you treat your cats, you should also treat the environment in order to get completely rid of the problem. In the UK I have used Acclaim without any problems.

Mar Vista Vet gives the history of flea control products and an overview of them all.

Mar Vista Vet discusses flea control.

Veterinary Partner compares Revolution (Stronghold), Advantage and Frontline.

The US Environmental Protection Agency here describes some of the thousands of problems arising from the use of Hartz products which it has investigated.

The US Environmental Protection Agency has now ordered Hartz to re-label some of its products, and to stop production of certain others.

Natural Remedies

Sometimes garlic added to food is recommended to control fleas, but since garlic is associated with Heinz body anaemia (see Which Foods to Feed), I would not follow this advice. Kansas State University quotes Dr Michael Dryden, associate professor of parasitology and a well-known flea researcher, who states ""There is no data available to substantiate the efficacy and safety of herbal flea preventatives. There's been one study on the use of garlic as a flea preventative and it showed nothing."

Vaccines

If you were to read the caution details on a packet of feline vaccine, you would see that it says the vaccine is for administration to healthy cats only. CRF cats are by definition not healthy, so I would not recommend vaccinations. Once Thomas had been diagnosed, my vet said she did not recommend giving him vaccinations, so we stopped. 

If you are in the USA, the American Association of Feline Practitioners now recommends that the standard vaccination package only needs to be given every three years anyway; so if your cat has been vaccinated in the last three years, you probably do not have any decision to make (the same does not apply to Europe, Australia or New Zealand, where different vaccines are used). As far as rabies is concerned, although a few US states only require the rabies vaccine to be given every three years, in others you may be required by law to have your cat vaccinated against rabies annually. In these states, you may be able to obtain an exemption if your vet confirms your cat should not be vaccinated for health reasons, so I suggest you begin to make enquiries about this some weeks or months before the next rabies vaccination is due. 

Of course, you may not be so much concerned about meeting legal requirements as anxious that your cat should have some protection against the diseases in question, particularly since s/he will be making regular visits to the vet, and may be exposed to illnesses there which could be of concern in view of the weakened immune status of the  average CRF cat. Most cats who have received vaccinations in the past will have some degree of residual benefit anyway, but if you are particularly concerned, you could have their vaccine titres checked (blood is taken and sent away to a specialist laboratory) to see how much protection they still have; although it should be remembered that titres only show a level of antibodies, and it is not always easy to know what level of antibodies can provide sufficient protection from a practical perspective. I suggest you discuss with your vet the best approach for your particular cat.

Colorado State University is currently working on a new test which will determine whether a cat needs to be vaccinated or whether previous vaccinations are still effective.

Finally, there is some recent research that indicates a very tentative link between standard vaccinations and the development of CRF; please see the Causes of CRF page for more information on this and about the recommendation that intranasal vaccines be used where possible.

The vexing vaccine issue: controversy, confusion continue to surround vaccination guidelines (September 2004) is an article in the Journal of the American Veterinary Medical Association.

American Veterinary Medical Association discusses the benefits and risks of vaccination.

Cornell University College of Veterinary Medicine also discusses the benefits and risks of vaccination.

Feline vaccination protocols (2002) is a paper presented by Dr Richard Ford to the WSAVA Congress 2002 which mentions the risk of using rabies vaccines containing adjuvants, which have been associated with a particular form of cancer.

Heska has information about intranasal vaccines.

Heska also has a presentation by Dr Lappin about the current vaccination debate (this is rather technical).

Arthritis Treatments

Since CRF cats tend to be older, some of them also have arthritis. Below are a few possible treatment options, and information on treatments to avoid.

Harpsie's Website has additional information on treating arthritis.

Cosequin

Treatments containing glucosamine and chondroitin, such as Cosequin, are usually safe for CRF cats; I found Cosequin did help Harpsie's arthritis to some extent, although according to The Mayo Clinic, it has been known to raise blood pressure temporarily in some human patients, and some patients have developed proteinuria. The increase in blood pressure may be because some of these products have a sodium base.  Be careful about using such products in a CRF cat and try to obtain a product without a sodium base if possible.

Adequan

Some people have also had success with Adequan, which is an injectible treatment, although this is is a relatively new treatment for cats (it is actually only approved for dogs) and many vets will not be familiar with using it in this way. Mar Vista Vet reports that when large doses were given to dogs, the dogs developed large kidneys. They therefore recommend being cautious when using Adequan in patients with CRF.

Metacam (Meloxicam)

One treatment to avoid for CRF cats, and probably for most cats, is meloxicam (Metacam). Metacam (meloxicam) is a non-steroidal anti-inflammatory drug (NSAID) available in both injectible and liquid (oral) form. It is approved for use in dogs in both forms, but since cats tend to metabolise NSAIDs very poorly, in the USA meloxicam is only approved for use in cats in its injectible form. This is because it is intended to be a one-off treatment as a painkilling injection following surgery.

Although meloxicam is very effective at controlling pain, I would not recommend its use in a cat who already has CRF, and I would be very cautious about using it in cats generally. Having said that, we did use it for Harpsie as a last resort when his arthritis flared up acutely in 2004 following a fall and he was in dreadful pain which other pain medications did not seem to help (he was literally screaming). It worked very well and caused no long term problems for him, but since Harpsie has PKD, we only used it at a very low dose, and much less frequently than normally recommended, and it still controlled the pain effectively. We checked his kidney values a month later.  We certainly would not wish to use it on an ongoing basis.

Longer-term, we have had extraordinary success treating Harpsie's arthritis with acupuncture. There is more information on acupuncture on the Holistic Treatments page. Harpsie's Website has additional information on treating arthritis, including more about his acupuncture sessions (with photos!).

Heat Pads

Heat pads are also a good idea for arthritic cats, particularly in cold or damp weather. A heat pad is a small flat heated pad with a fleecy cover - it looks like a little flat cat-sized bed. You just plug the heat pad into the mains and then the pad stays at the chosen temperature constantly, unlike a hot water bottle. You must of course keep an eye on your cat while he or she is using this since it is electrical equipment, but certainly we never had any problems with overheating, and Harpsie used his almost constantly in winter.

One Final Treatment...

is TLC (tender loving care). Don't under-estimate it! It can work wonders, as anybody who has seen a cat pull through against the odds can testify.