Reasons for Loss of Appetite

Average Feline Calorie Needs

The First Thing to Try: Vitamin B

Additional Nourishment

Assisted Feeding

Appetite Stimulants (Mirtazapine, Cyproheptadine, Diazepam, Steroids)

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Which Treatments are Essential

Fluid and Urinary Issues (Fluid Retention, Infections, Incontinence, Proteinuria)

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General Health Issues in a CKD Cat: Fleas, Arthritis, Dementia, Vaccinations

Tips on Medicating Your Cat

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Working with Your Vet and Recordkeeping

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Nutritional Requirements of CKD Cats

The B Vitamins (Including Methylcobalamin)

What to Feed (and What to Avoid)

Persuading Your Cat to Eat

2007 Food Recall USA

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Home > Diet and Nutrition > Persuading Your Cat to Eat

Why Getting Food Into Your Cat is So Important

11 guidelines for conservatively treating chronic kidney disease (2007) Polzin D Veterinary Medicine Dec 2007 states that "in many or most dogs and cats with chronic kidney disease, death or euthanasia results directly or indirectly from starvation." This is truly shocking, not least because it is so unnecessary. Are you really going to let your cat starve to death? I doubt it!

There is another major concern with cats who are not eating. This is that cats who do not eat may develop a condition called hepatic lipidosis (fatty liver disease) where the liver starts to function abnormally. Hepatic lipidosis can happen after just a day or two of not eating and can be life-threatening. 

The American Animal Hospital Association recommends that you should contact your vet if your cat has not eaten for one or two days. Mar Vista Vet has some information about hepatic lipidosis, and mentions that a cat who has eaten only half to three quarters of his or her normal food intake for two weeks is also at risk.

In! Getting calories in: feeding the inappetent or anorectic cat (2012) Scherk M Presentation to the 73rd SCIVAC International Congress 2012 p431-432 is an excellent article about how to persuade your cat to eat.

So remember your new mantra: my cat is going to eat!

Reasons for Loss of Appetite

If your cat does not want to eat, please do try to find the cause (such as nausea, dehydration and/or anaemia). You can check the Index of Symptoms and Treatments (scroll down to Appetite Loss) for more information on possible causes of inappetence. Treating whichever of these potential causes is present is essential, and may even solve the problem for you.

However, your cat needs to eat whilst you are sorting out the possible causes of inappetence. Plus even after treating whatever problems may be present, since cats eat to live rather than the other way round, you may find your cat has got out of the habit of eating and has to be tempted into doing so again. The good news is, once you have got your cat eating again, s/he may feel better for it and soon get back into the habit. 

If a cat is truly dying, the digestive process will cease to function and the cat will not need food. If you fear this time has come, you will not only see a refusal to eat but many other symptoms as well — check out The Final Hours for more information. But please don't assume your cat is dying simply because s/he won't eat! Not eating is one of the most common symptoms in CKD cats, and appetite can come and go, so don't fear the worst just because you see this symptom. For the vast majority of CKD cats, food is essential and part of the treatment plan, and many people are amazed when they see how much better their cat looks and feels once s/he has taken in some food.

Please see the Nutritional Requirements page for an explanation of your cat's physiological needs and a discussion of the reduced protein debate, and the Which Foods to Feed page for what to do if your cat refuses to eat the therapeutic kidney diet which your vet recommends.

Feline Calorie Needs

Whilst it is hard to be precise, a cat needs approximately 30-35 calories per day per pound of body weight, or possibly more if the cat is particularly active. As an example, a 9 lb cat would need 270-315 calories a day. Therefore, as you can see, feeding a teaspoonful of food a day is not going to be enough to maintain your cat's weight, let alone increase it if your cat is too thin.

Calories matter. If you are just trying to get food into a cat who isn't eating much voluntarily, it makes sense to use a calorie- and nutrient-dense food if at all possible. There is information below about foods that your cat may be prepared to eat which provide additional nourishment.

Please read more about the calorie needs of CKD cats here.

The First Thing to Try: Vitamin B

Your cat will probably benefit from vitamin B supplements in the form of vitamin B complex and a separate vitamin B12 supplement. Many people find these help their cats with appetite and wellbeing, and they are widely available and very safe, though of course you should not use them without your vet's knowledge (many vets, including mine, offer these routinely).

Please see below and the separate Vitamin B page for more information on suitable brands.

Additional Nourishment

• Eggs

• Hill's a/d Prescription Diet

• Liquivite/Royal Canin Renal Liquid/EmerAid Intensive Care HDN Kidney

• Dairy

• Baby food

• Meat or fish pastes

• Human food

• Fancy Feast

• Nutri-Cal

Eggs, Particularly Egg Whites

Egg Benefits

If you want to provide your cat with additional nourishment, the best choice is probably eggs, which contain high quality protein from a CKD perspective (see Nutritional Requirements for more about this concept). Washington State University College of Veterinary Medicine has stated: "Proteins with high biologic value can be readily converted to body proteins with minimal waste production. Animal proteins have a higher biologic value than vegetable proteins. Eggs have the highest biologic value." There is more about this concept of here.

For a CKD cat, the egg white alone is usually a better choice, because this provides additional protein but does not contain high levels of phosphorus. According to the US Department of Agriculture FoodData Central, one large egg white weighs about 33g and contains 19 calories, 3.64g protein, no fat and only 5mg of phosphorus. This is a lot less phosphorus than a chicken breast, and the protein in eggs is more digestible.

A human study, Organic and inorganic dietary phosphorus and its management in chronic kidney disease (2010) Noori N, Sims JJ, Kopple JD, Shah A, Colman S, Shinaberger CS, Bross R, Mehrotra R, Kovesdy CP, Kalantar-Zadeh K Iranian Journal of Kidney Disease 4(2) pp89-100, reports that "fresh (non-processed) egg white (phosphorus-protein ratio less than 2 mg/g) is a good example of desirable food, which contains a high proportion of essential amino acids with low amounts of fat, cholesterol, and phosphorus."

Another human study, Dietary egg whites for phosphorus control in maintenance haemodialysis patients: a pilot study (2011) Taylor LM, Kalantar-Zadeh K, Markewich T, Colman S, Benner D, Sim JJ & Kovesdy CP Journal of Renal Care 37(1) pp16-24, and discussed in Renal and Urology News (2008), found that egg whites even helped lower phosphorus in patients who ate six cooked egg whites in place of a meal each day.

Egg White Cautions

Although egg whites are nutritious with minimal waste production, they do not have many calories, so you do not want them to make up too high a percentage of your cat's daily food intake. One to two egg whites each day might be appropriate, if your vet agrees, as long as your cat also eats a complete cat food.

Eggs may inhibit iron absorption. Prediction of dietary iron absorption: an algorithm for calculating absorption and bioavailability of dietary iron (2000) Hallber L& Hulthén L American Journal of Clinical Nutrition 71(5) pp1147-60 found that eating eggs reduced iron absorption by around 27%. This applies more to the yolk than to the white but be careful if your cat is anaemic.

Egg White Formulations

Egg whites are available either in the old fashioned way (i.e. from a fresh egg), or in liquid form (also fresh) or powdered versions. Some brands contain onion, which you should avoid. If you buy dried (powdered) egg whites, make sure they are pasteurised (they usually are).

Since the cartons contain quite a few egg whites, you may not use them up quickly enough, but it should be fine to cook some of the leftover egg whites, then freeze them. It is possible to freeze some liquid egg whites without cooking them first, but check the brand's instructions. Some people freeze the egg whites in ice cube trays so it is easy to take out just what they need.

Egg White Preparation

It is important to cook egg whites until they are hard, because uncooked egg white contains something called avidin, which combines with biotin (one of the B-complex vitamins) to make it unavailable, and CKD cats do need their B vitamins. Cooking the egg whites destroys the avidin.

Therefore you need to check whether the type you buy has already been cooked.  Liquid ones usually have not been cooked, but powdered ones may be cooked. Double check whether what you has is cooked. Just because it is pasteurised doesn't mean it is cooked, and pasteurisation alone is not sufficient to deactivate the avidin. If you have to cook them yourself, make sure you do it thoroughly.

If you are using fresh or liquid egg whites, you can scramble them and serve them to your cat, or add cooked egg whites (chopped) to your cat's food. Some cats will eat them when served in this way but many won't. Therefore you may have to use a blender to make them fine enough to add to the food without being off-putting to the cat.

If you are using powdered cooked egg white, you can often just sprinkle it on your cat's food and mix it in. As a rough guide, two teaspoons of powdered egg white is roughly equivalent to one egg white, but check on the packet.

Egg White Sources

In many countries you can buy cartons of egg white, both fresh and dried, in supermarkets.

Egg White Sources: USA

• A brand called All White consists of nothing but raw egg whites.

• Amazon sells a dried product by Now Sports.

• Amazon sells another dried product.

Egg White Sources: UK

• Two Chicks Free Range Liquid Egg Whites are available from most UK supermarkets, including Sainsbury's, Waitrose and Tesco. There are fifteen free range egg whites in a carton, which should be stored in the fridge.

• Hobbycraft sells Dr Oetker powdered egg white.

Egg White Sources: Australia

• Simply Egg Whites are one option.

Liquivite/Royal Canin Renal Liquid/EmerAid Intensive Care HDN Kidney

There are several liquid supplements available for cats, which may be helpful if you are feeding your cat via a syringe or a feeding tube, or if you want to get more calories into your cat. They could also be useful if your cat is not eating normal cat food (e.g. if your cat is only eating baby food) because some of them are nutritionally complete.

Liquivite is a canned liquid food made from chicken, liver, beef and eggs, with a relatively low phosphorus content (0.75% on a dry matter analysis (DMA) basis, though it does have a relatively high fat content. It is available from Pet Meds.

Renal Liquid by Royal Canin became available in Europe in 2017. This has a low-lactose milk base and is designed to be suitable for tube or syringe feeding, though some cats will lap it up voluntarily. Pet Drugs Online sells 3 x 200ml bottles for £22.80. It is also available from VioVet.

EmerAid Intensive Care HDN Kidney is a "highly digestible nutrition" product which is available in 100g or 400g pouches, and which has a 30 day  shelf life after opening. It does state it is for intermittent or supplemental feeding only.

Hill's a/d Prescription Diet

Hill's a/d Urgent Care is a food specially formulated for convalescent cats: it has high levels of liver, is very mushy and extremely smelly. Quite frankly, the smell makes me feel ill; so naturally, all my cats adore it. Once Thomas gave up on ham, we were at our wits' end; but Hills a/d kept him going through his crisis and was a real lifesaver. Because it is so mushy, it is very easy to use for syringe feeding.

This food is a therapeutic food which in theory is only available from vets. It should not be fed to a CKD cat long-term because it contains a lot of liver (too high in vitamin A) and is high in phosphorus (1.15% on a DM basis); but it is excellent for short periods of crisis and/or convalescence. Hill's a/d contains around 180 per can, or 33 calories per ounce.

Once opened, a can of Hill's a/d should be kept for a maximum of 36 hours.

Dairy

It is estimated that around 80% of cats are lactose intolerant, which can cause diarrhoea and vomiting. For this reason, it is usually recommended that cats are not fed milk. If your cat is not lactose intolerant, it is usually safe to feed milk, though it does contain protein and phosphorus, so is best kept as an occasional treat. Full fat milk actually contains less phosphorus than skimmed milk, around 0.84% (skimmed milk contains over 1%), and the additional fat in full fat milk may be helpful for CKD cats who tend to be thin.

If your cat is lactose intolerant, there are special lactose-free milks available for cats, such as Cat-Sip, which also has added taurine.

Many cats seem to like cream cheese. One of my cats got a little cream cheese every day for over thirteen years (it started because she was abused before she came to us and frightened of men, so my husband was trying to bribe her to like him) and it seemed to help with hairballs. If your cat likes cream cheese, ask your vet about giving a little to your cat occasionally.

Baby Foods

Baby foods can be helpful if you are trying to tempt your CKD cat to eat in the short-term. Aim to buy the simple meat-based foods rather than those containing veggies and fruit.

Please also ensure you purchase a food without any onion, garlic or onion powder . In principle baby foods sold in the USA have to list every single ingredient on the jar, so if the ingredient is not listed, the food should not contain it.

Hepatic lipidosis — managing and feeding the anorectic cat (2016) Scherk M Music City Veterinary Conference says "A cat eating small amounts of baby food will not meet his caloric needs until he eats two – three jars/day. Meat baby food is not balanced, but is sufficient for several weeks."

Do not feed baby foods exclusively long-term, because they have an imbalanced phosphorus:calcium ratio (Pet Education explains more about this), plus like other human foods they lack taurine, an amino acid which cats need to obtain from their food. A lack of taurine in a cat's diet can cause serious heart and eye problems.

If you feed baby food exclusively for longer than a few days, add 500mg of taurine to it, which is not perfect but it will reduce the risks somewhat. However, it is OK to feed a little baby food each day without taurine e.g. when giving pills, as long as it is in addition to a more balanced (usually a commercial) cat food. Be guided by your vet.

Wholesome Baby Food has some recipes for making your own baby foods.

USA

You want the type of foods which are very smooth and meat-based only, without vegetables or fillers such as pasta. Look for Gerbers 2nd Foods Meats, Beech-Nut Stage 1 or Heinz Stage 2 Beef with Broth or Chicken with Broth. These foods are safe at the time of writing, but formulations can change, so do check the labels. 

Here are the foods available in each range:

My cats liked the Gerbers 2nd Foods Meats range the best, especially the ham flavour. These foods kept Indie going when she had largely lost her appetite after extensive dental surgery. They are fairly runny and she was able to lap them up with her tongue.

Although baby foods are relatively high in protein, they are low in phosphorus — they contain about the same amount of phosphorus as a portion of therapeutic kidney food containing the same number of calories. The ham variety is currently the lowest in phosphorus and protein, and although people worry that ham baby food will be high in sodium, it actually contains less sodium than virtually all therapeutic kidney diets. Here is some information about the levels of phosphorus, protein, sodium and fat in a number of US baby foods as at June 2020 (all foods of a particular flavour are similar in terms of content):

Gerber's baby foods are available in most supermarkets, though ham seems to be harder to find lately (try Walmart). They are sometimes cheaper (less than $1 a jar) at Walmart or Wegmans. Heinz and Beech-Nut are also widely available.

Amazon sells twelve jars for around US33 plus shipping.

Vitacost sells Gerber and Beechnut foods for around US$1.17 a jar.

UK

When I tried using baby foods in the UK with Tanya, I had great difficulty finding anything suitable because most of the UK baby foods seem to have large amounts of carbohydrate rather than the meat which cats usually prefer and need. Fortunately Heinz have introduced a food called Four Month Mum's Own in Beef Purée flavour which appears to be suitable.

Ulula sell baby foods online in the UK, including the organic Holle brand which is water, pure meat and rice flour. It is available in beef and chicken varieties.

Amazon UK has a seller who offers Gerbers 2nd Foods chicken flavour in packs of twelve, though it is very expensive (around £85 including shipping).

Vitacost sells Gerber and Beechnut foods for around US$1.17 a jar and appears to ship to the UK.

Meat or Fish Pastes (Potted Meat)

If you are in the UK and are having difficulty getting hold of suitable baby foods, you could consider using meat or fish pastes instead. I used these for Tanya, and they were one of the few things she was prepared to eat.

I have found Marks and Spencer Potted Salmon to be very popular with most of my cats but a beef flavour is also available if required, though check the ingredients list for onion or garlic (the Salmon version does not contain either). These products are very smooth, so are easy to get your cat to lick off your finger if necessary. I haven't tried to syringe them but imagine they would be suitable if watered down.

If you are outside the UK, supermarkets in many other countries also sell potted meats.

Human Food

This is certainly not the best food for a CKD cat, but if your cat is recovering from a crisis or being extremely pernickety, you may have to resort to offering tasty human foods to tempt your cat back into eating.

Chicken or lightly cooked fish are possibilities. If you're in the UK, you can also go to the chippy — my cats will almost always eat fish from the chippy (with the batter removed).

Thomas would only eat ham for two weeks when his anaemia was at its worst. Even though the levels of sodium and nitrates in the ham were very unhealthy, eating ham was better than not eating anything at all (though I think other options on this page would be a better choice). Many commercially sold chickens have a lot of salt too.

Do not feed these sorts of foods long-term, because they lack the nutrients which a cat needs, particularly taurine, an amino acid which cats cannot manufacture themselves, and a lack of which can cause heart and eye problems; but in order to kick-start eating, they can be helpful. Please do not feed your cat anything containing onion or garlic and be careful about feeding tuna (see Which Foods to Feed).

Nutri-Cal

You may be offered a high calorie supplement called Nutri-Cal, which comes in a tube and is stocked by many vets. It is not my first choice because it is relatively high in carbohydrates rather than protein and has some additives. However, it does help tempt some cats to eat, so it might be of help during a crisis, though some of the other choices on this page are probably better.

Nutri-Cal appears to contain a relatively high amount of Vitamin A, so do check with your vet before using this, because too much vitamin A is not good for CKD cats.

Fancy Feast (Gourmet Gold)

Fancy Feast often seems to be considered to be a  "bad" food. I've never quite worked out why this is, but I get the impression Fancy Feast is considered to be akin to "junk food" that is full of by-products. That's what many humans seem to think anyway. Most cats, however, love Fancy Feast, to such an extent that in some circles (my house) it is known as "kitty crack."

Many Fancy Feast flavours are not particularly complicated foods. In fact, many of them have broth as the first ingredient rather than the more commonly seen water. Not only that, but, because many flavours do not contain added gluten, Fancy Feast was not affected by the 2007 pet food recalls, unlike many so-called premium brands. And from a CKD perspective, some of the tinned flavours are not excessively high in phosphorus for a non-therapeutic diet.

In fact, until mid 2010, the Fancy Feast flavours with the lowest phosphorus levels had phosphorus levels of under 0.5%, similar to those of the lowest phosphorus CKD veterinary food. Unfortunately Purina decided to change their formulations and sadly no Fancy Feast flavour now has a phosphorus level below 1%. This is higher than you ideally want, but may be worth considering if your cat simply won't eat anything else. The pâté-style foods (labelled Classic) tend to have higher levels of phosphorus (1-2%). The marinated and grilled flavours tend to have high sodium levels, so would not be a good choice for cats with high blood pressure. The Appetizers are not complete foods, so should not be fed exclusively. You can check the food data tables for more information on the levels of phosphorus and sodium in some of the Fancy Feast varieties.  

I'm not claiming that Fancy Feast is perfect. Some flavours contain a preservative called sodium nitrate (or nitrite). Nitrite poisoning in cats and dogs fed a commercial pet food (1997) Worth AJ, Ainsworth SJ, Brocklehurst PJ & Collett MG New Zealand Veterinary Journal 45(5) pp193-195 reports on the effects of this preservative on some cats (note: there is no evidence that the food used in this study was Fancy Feast).

But basically, most cats do seem to love Fancy Feast, and even those who are not feeling too good may eat Fancy Feast. Some cats on Tanya's Feline CKD Support Group have eaten nothing but Fancy Feast for years, and have done well on it, with the addition of phosphorus binders when needed (i.e. if their blood tests show phosphorus levels that are too high).

The pâté-style foods (labelled Classic), whilst too high in phosphorus to use as a regular diet for CKD cats, are often easier for cats with poor teeth to eat than the other types (grilled, marinated etc.), and can also be mixed with water until smooth and used for syringe feeding or as a base for mixing medications.

Therefore if you live in the USA, I would recommend at the very least keeping a few cans in the cupboard in case of need. It was the only thing Indie would eat when she was sick once.

The nearest UK version of Fancy Feast, judging by the tins, seems to be Purina Gourmet Gold. Unfortunately it does not appear to have the same "kitty crack" appeal of Fancy Feast, plus it seems to have much higher levels of phosphorus. Testberichte (Test Reports) in Germany says some flavours contain too much phosphorus, but is not very specific about this. However, it may be useful to try this in times of crisis. 

Tempting Your Cat to Eat

Since CKD cats often have poor appetites, this section has tips on how to encourage your cat to eat. Some of these methods take seconds, so they are definitely worth a try. If you can persuade your cat to eat of his/her own accord, it is usually much less stressful for both of you.

Also check out the previous section on additional nourishment, because some of the suggestions there may help.

• Raising the food bowl

• Feeding location

• Food presentation and storage

• Warming food

• Sleepy eating

• Food texture

• Pretend to eat it yourself

• Feeding little and often

• "Kitty smorgasbord"

• Broth/puréed food

• Tempting extras

• Catnip

• Tuna water

• Acupuncture

Food Texture

Some people have found that cats who are off their food seem to prefer pâté-type foods to more lumpy foods. If you offer more solid foods, you will often find that your cat merely licks off the gravy. You can either buy pâté-type foods (many of Hill's pâté-style foods are low in phosphorus), or you can use a liquidiser or blender (or a fork, if you don't have a blender) to make any food smoother.

A popular choice in the USA is the Magic Bullet, which costs around US$40-50. It is available from Bed, Bath and Beyond. Amazon sells another blender, the Maxi-Matic Elite Cuisine, for US$15.99. In the UK, Amazon sells the Kenwood CH180 mini chopper for £19.99.

Depending upon what you are feeding, you may be able to blend larger quantities and freeze some of the portions.

Some people have had success by squashing small portions of canned food into little balls and feeding them to their cats by hand (see below).

I have found that if I pretend to eat my cats' food, this can encourage them to eat it themselves. Don't forget the loud appreciative noises! I haven't yet gone as far as actually eating their food, but give me time...

Some people also find that offering a food to another feline family member may tempt the sick cat to eat the food, especially if you make it look as if you are trying to give the other cat a secret treat.

Broth/Puréed Food

Some people have found homemade chicken broth (just boil the chicken in water, there is no need to add any vegetables, definitely not onions) very helpful for their CKD cats. It is not high in calories but can help make foods more appetising and also increase fluid intake. It can either be added to food (particularly therapeutic diets) or simply given to the cat to drink. Some people freeze it in cubes.

When buying chicken to make the broth, make sure that it does not contain added broth, which may contain sodium and onion. Many commercially sold chickens have a lot of salt, The Center for Science in the Public Interest has more information about this. You can check how much sodium is in a chicken by looking for sodium in the nutritional information on the packaging: anything over 100mg of sodium means that sodium has been added.

Some people have tried a simpler approach and simply add lots of water to their cat's canned food in order to make it soupy. You can use a blender if necessary to make it fairly smooth. Cats with mouth ulcers in particular may prefer food with this texture.

If you're not culinary-minded, commercially produced broths are now available.  Fancy Feast broths are available in the USA, which many cats seem to like, and some of them are pretty low in phosphorus:

Purina Soups seem to be broadly equivalent products in the UK, but I do not have the phosphorus levels for these as yet.

Sheba Signature Broths are even lower in phosphorus:

Friskies Lil' Soups are another option:

In the UK Applaws makes a range of Cat Toppers, including Chicken Soup with Chicken. They are available from Pets at Home, among others. I do not yet know the phosphorus content.

Please check the phosphorus content with the brand in question before feeding the broths because levels may well have changed.

Feeding Little and Often

Many CKD cats no longer routinely ask for food, or not frequently enough to maintain their weight, so they need your help. Try to offer your cat small amounts of fresh food at regular intervals, if necessary taking the food direct to your cat (we used to have a rule that cats eat in the kitchen but that soon went out the window once we were faced with a sick cat). Just offer a spoonful at a time. If your cat eats it, offer a little more.

If you do have the time to offer food frequently, you can find that although your cat only eats a little each time, over the course of a day it can add up to a reasonable food intake. You may also find that this reduces the build up of gastric hyperacidity in your cat.

If you are out at work all day, you could try using a timed automated feeder which opens separate compartments at times of your choosing so that your cat can have access to fresh canned food. These are also useful at night. See Which Foods to Feed for links to feeders.

Kitty Smorgasbord

Until your cat is stable, you may have to resign yourself to having a "kitty smorgasbord" available for a while. This means you have a selection of foods for your cat to choose from, which you rotate to suit your cat's current preferences. When Harpsie (non-CKD but he had a severe kidney infection) was sick and off his food, we ended up with eighteen different foods on offer. We had to build a shelf just to hold them all!

Obviously we didn't offer all these foods in one go! We would offer him one food and if he wouldn't eat it, we would try another. We found he might eat one of the foods one day, then refuse it the next. Sometimes we would offer him five or six foods before we found one he would eat. Then a week or so later, a food he had previously turned down might be back in favour.

We also found that he might refuse a food in the kitchen but be prepared to eat the same plateful of food in the lounge. Or he might eat the food if we moved it back into the middle of the plate. The plate mattered too: he seemed not to like plastic plates but preferred china (well, he was an English gentleman...). Flat plates were also important (see above).

You can also mix foods, e.g. put a little baby food or a tasty extra on top of the food you really want your cat to eat.

Tempting Extras and Treats

These are items which you can sprinkle on your cat's food in order to make it more tempting for your cat. I have had good luck with Salmon Liv-a-Littles in particular.

Fishy Extras

Fish can be a bit of an issue for cats (see Which Foods to Feed), but a little sprinkled on the food each day to tempt your cat to eat is probably OK.

• As mentioned below, sometimes adding a little of the water in which tuna is packed to food can make it more attractive to cats.

• Alternatively you might want to try powdered tuna which you sprinkle on the food and mix in — this appeals to many cats.

• Dried bonito flakes are often available cheaply at Asian markets. Bonito flakes shows the composition of one brand of bonito flakes. Try to buy a brand free of additives and without added salt. I use Cat-Man-Doo for my own cats.

• In the UK Zooplus sells the Cosma brand of freeze-dried treats. They are available in tuna, chicken, duck and beef varieties, and you can also buy a mixed taster pack to see which your cat prefers. 

• Zooplus also sells other brands of dried fish, search for dried fish. Thrive is liked by some members of Tanya's CKD Support Group and appears to contain 1% phosphorus on a dry matter analysis basis.

Meaty Extras

Although these tend to be pure meat and are therefore relatively high in protein and phosphorus, you use so little when you sprinkle them on food that it should not be a problem.

• Beaphar Kidney Support Treats are a possibility in the UK and Europe.

•  

• Liv-a-Littles are freeze-dried pieces of 100% chicken or salmon which many cats seem to love sprinkled on their food; they are available from Petco and Wholefoods.

• Pure Bites are available in a variety of flavours.

• In the UK Zooplus sells the Cosma brand of freeze-dried treats. They are available in chicken, duck, beef and tuna varieties, and you can also buy a mixed taster pack to see which your cat prefers.

• Thrive in the UK makes freeze-dried chicken which you can sprinkle on your cat's food.

• Whiskas Temptations are hugely popular with many cats, including my own.

• Hartz Delectables Bisques are liked by many cats. They are available from Amazon.

• Some people on Tanya's Support Group like to add a little goose fat or duck fat to their cat's food, both to make the food more palatable and to increase their cat's calorie intake. In the UK many people roast their potatoes in these fats, so you can find them in supermarkets, usually near the bottled oils. In the USA you may be able to find these fats in the gourmet section of your supermarket. Wholefoods sells the Epic cage free duck fat brand, which is also available from Amazon.

Catnip

I am sometimes asked if it is acceptable to give catnip to a CKD cat. It is fine, and in fact may act as an appetite stimulant in some cats. However, not all cats react to catnip — this is a genetic trait.

Cats International has some information on catnip.

Tuna Water

Whilst tuna itself is not appropriate for cats (see Which Foods to Feed), one possible compromise is to add the water in which tuna is packed to your cat's prescription or other diet in order to moisten it and make it more palatable. Tuna packed in water may actually be packed in a type of broth, which may contain onions; and other brands may contain high levels of sodium, so you need to be very sure the brand you use is acceptable.

Starkist Selects No Salt Added Tuna (canned) contains only tuna and water.

Amazon sells Crown Prince tuna in water with no added salt.

Trader Joe's sell their own brand Low Sodium Tuna packed in water, and other chains may do the same.

Acupuncture

When my cat, Harpsie, began having acupuncture (for his arthritis), there was a noticeable improvement in his appetite. I don't know if this was a direct result of the acupuncture itself, or whether being in less pain from the arthritis made him feel better generally; but I know of several CKD cats who receive acupuncture solely for appetite stimulation, and it seems to work for them.

Holistic Treatments has more information on acupuncture.

Assisted Feeding

You will probably have times when your cat refuses to eat. Naturally, you must try to address all possible causes of inappetence, such as gastric hyperacidity, mouth ulcers and nausea (see Index of Symptoms and Treatments), and the suggestions above to make the food seem more appetising. But if all else fails, there are a couple of other things you can try.

• Company while eating

• Feeding by hand

• Syringe feeding

• Feeding tubes

Company While Eating

We found this helpful with both Tanya and Thomas. We would sit by them encouraging them to eat, praising each mouthful. It does work for some cats. If Harpsie was lying near us on the sofa, we also used to place a plate of food nearby, also on the sofa, so he did not have to move far to eat.

We also found that if we pretended to eat a food, the cats would try it too. See above for more on this.

Feel free to be inventive. I remember hearing from one lady some years ago who was trying in vain to get her cat to eat. She failed, and lay down on the floor feeling miserable. Her cat promptly climbed on her stomach and lay there, so she gently reached for the food bowl and placed it in her torso. Her cat ate! From then on, she found she could always get her cat to eat of his own accord if she did this. It didn't require much effort on her part, in fact it gave her a chance to relax, happy in the knowledge that her cat was eating, so it was a win win situation.

Feeding by Hand

This is the next stage, where you lift the food out of the bowl and encourage your cat to lick it off your finger or a spoon.  It can take hours, and your cat will probably drop lots of the food, but we found this really helped persuade both Tanya and Thomas to eat.

This also helped with Lily (right), our kitten with FIP. We microwaved some white fish (cod) on high for about five minutes (your microwave might vary) and then fed her the cooked flakes by hand.

Some people have had success by squashing small portions of canned food into little balls and feeding them to their cats by hand.

Syringe (Assisted) Feeding

Finally, you can try what many people refer to as force feeding, but what I prefer to call assisted feeding. This entails placing your cat's food into a syringe and syringing it gently into the cat's mouth. Hill's a/d in particular can be made into a mush with water and syringed in easily. Alternatively, you can use a pâté-type food such as Fancy Feast (Gourmet Gold in the UK) or some other canned food and purée it using a mixer or blender. However, do not assist feed a food you would like your cat to eat in the future, because some cats may develop an aversion to a food they eat while they are sick.

Add water to make it more liquidy if it is too hard to squeeze out of the syringe, then draw it up into a syringe. You don't usually need too much water, add a little and see how it is; you can always add more if necessary. Using warm water can make the food more attractive to your cat. If necessary, use a strainer to make the food smoother, Amazon sell one.

If you assist feed, you may as well aim to feed a reasonable amount of food to your cat, bearing in mind your cat's calorie needs, though you will probably want to start with smaller amounts until you and your cat get used to the process, especially if s/he has not been eating much recently. How much to give depends upon how much weight your cat has lost, and how many calories the food contains. You can tell if you are feeding enough if your cat’s weight stays the same or (if your cat is too thin) gains weight.

However, just as a cat doesn't eat a day's worth of food in one meal, so you don't need to assist feed in one big session; if you can, spread the food over several smaller sessions a day. I used 10ml syringes and would only give one syringe full at a time, but doing this every 2-3 hours added up to a reasonable amount of food. If you're out at work for most of the day, you will have to give more at one time, but to make things easier, you can make up several syringes at a time and store them in the fridge before use. If you work, you should still be able to feed three times a day (before work, after work and before bed). Yes, it is a commitment, but in some ways it is less time-consuming than following your cat around with platefuls of food.

It is also important to assist feed properly: hold your cat upright, make sure the food is reasonably mushy so it flows smoothly, go slowly, try to stay calm. Insert the syringe in the side of the mouth, not directly in the front, so as to reduce the risk of the food going down the wrong way; and give your cat time to swallow each mouthful. You must also only syringe in a little food at a time and give your cat time to swallow it. All this is in order to avoid the risk of aspiration pneumonia. Pet Place has more information on this, as does Cornell University College of Veterinary Medicine.

Don't worry if your first session doesn't go too well, you and your cat both need time to get used to this new routine. You will probably both be a bit messy, so wear old clothes, cover your furnishings with a throw and have a damp cloth close at hand to wipe your cat. Some people find it easier to wrap their cat in a towel. It may be more comfortable for your cat if you warm the food but be careful not to have it too hot, you don't want to burn your cat's mouth.

You can feel really mean when you assist feed, and it doesn't help that some vets claim that if a cat stops eating, it's time to let go. All I can say is, I'm glad that doesn't apply to humans too because I would have been dead years ago if so! I saw in the new millennium with a nice bout of flu during which I was unable to eat a thing.

We had to assist feed Tanya occasionally at our vet's suggestion; luckily it was usually only necessary for a day or two, although some people on Tanya's CKD Support Group do this on an ongoing basis. If you are doing this on an ongoing basis, I would feed a therapeutic kidney diet. However, don't assist feed a food you would like your cat to eat in the future, because some cats may develop an aversion to a food they eat while they are sick.

Tanya was a very independent cat, but she coped far better with assist feeding than we would have expected, and your cat might be the same. Assist feeding can actually reduce stress for both of you. You know your cat has eaten enough rather than watching anxiously and trying to ascertain if his/her food intake has been sufficient that day. Your cat is not being hassled by you waving twenty different foods under his/her nose. Plus you will also save money by not having to throw away twenty different rejected foods each day.

Kathy assist feeds Toady is a helpful video on how to assist feed a CKD cat.

Syringe feeding Coco is a good, clear video showing Marga feeding Coco (this is in Dutch but you will be able to see what Marga is doing).

Syringe feeding Jasper is a video from Roni. When she first began, she could barely get three squirts in but here, three months later, you will see she can easily feed a decent amount of food.

Holisticat has detailed instructions on how to assist feed. 

Choosing a Syringe

The size syringe you should choose depends upon how strong your hands are - the smaller and weaker your hands are, the harder it is to push a larger syringe. I have weak hands and found a 10ml one worked best for me with Tanya. Some people prefer smaller ones, such as 3ml or 5 ml.

Syringe Sources

Some pharmacies in the USA will give you syringes for free if you ask.

Lambert Vet Supply in the USA sells Baxter syringes with an "O-ring", which last longer and which some people find easier to push than standard syringes.

Pet Supplies 4 Less also sells Baxter syringes.

Innovet makes soft tipped syringes which many members of my support group like. They are also available from Amazon.

California Vet Supply sells Dial-a-Dose syringes with a dial to help control how much food you give at one time.

The Squirrel Store sells O-ring syringes.

Amazon sells packs of two Easy Feeder syringes, one of which is for giving water, the other is good for assist feeding.

Pets at Home in the UK sells Mikki hand feeder syringes.

Health Care Logistics sells syringes which are also popular with members of my support group. They will ship to Canada.

Feeding Tubes

If all else fails, your vet may suggest a feeding tube. This is a device which is implanted into your cat and you then simply pour food and medications into it.

• When to use feeding tubes

• Feeding tube types

• Feeding tube tips

• Feeding tube links

When to Use Feeding Tubes

These tubes can last for up to a year, but are normally only used until the cat is eating enough to maintain his/her weight. Most people seem to leave the tube in until the cat has been eating enough unaided to maintain his or her weight for at least two weeks. You should monitor your cat's weight closely (you can find sources for suitable scales here).

Some vets are opposed to feeding tubes for CKD cats, believing that if a cat reaches this stage, it is cruel to keep them alive; but Treatment recommendations for CKD in cats (2019) International Renal Interest Society  states that they should be considered for Stage 4 cats: "Intensify efforts to prevent protein/calorie malnutrition. Consider feeding tube intervention (e.g., percutaneous gastrostomy tube)."

ISFM consensus guidelines on the diagnosis and management of feline chronic kidney disease (2016) Sparkes AH, Caney S, Chalhoub S, Elliott J, Finch N, Gajanayake I, Langston C, Lefebvre H, White J & Quimby J Journal of Feline Medicine & Surgery 18 pp219-239 do not specify in which stage CKD cats should receive feeding tubes, merely saying "if cats remain too nauseous or unwell to maintain sufficient voluntary food intake despite appropriate treatment, placement of an enteral feeding tube (eg, oesophagostomy or gastrostomy) should be considered, and anecdotal reports suggest these can be valuable in maintaining food and fluid intake in some cats with CKD."

The kidney patient: what's for dinner? (2010) Francey T Presentation to the World Small Animal Veterinary Association World Congress states "The initial reluctance of most owners to accept feeding tubes that they view as artificial life support, is often overcome when truly exposed to them. Esophagostomy tubes or PEG tubes are commonly used for other indications and they can also markedly improve the quality of life of small animals with advanced CKD. Administration of water in sufficient amounts to help maintaining optimal hydration, ease and reliability of administration of medications, and administration of the qualitatively ideal food in sufficient quantity are the main benefits of feeding tubes. The use of this type of nutritional support is the only way to push the limits of the medical management of small animals with CKD without compromising their quality of life."

I would say the vast majority of Tanya's CKD Support Group members who have tried feeding tubes have had good results, even for cats with less advanced CKD; feeding tubes may also be helpful for cats with pancreatitis.

Feeding Tube Types

There are three main types of feeding tube

VCA Hospitals discusses the different types of tube.

Oesophageal Tube (E-tube)

The oesophageal tube, which can normally be inserted with sedation only, is inserted at the neck and runs down to the oesophagus. Usually food fed through such a tube must be blended. Your vet can tell you how much and how often to feed, though to start with you will usually have to feed small amounts each time, gradually increasing the amount you give.

These tubes can be left in for months if necessary.

The University of Missouri Veterinary Health Center explains more about oesophageal tubes.

Esophagostomy feeding tubes (2014) Hodshon B & Tobias KM Clinician's Brief Feb 14 pp66-72 discusses these tubes.

Kitty Kollar sells special collars to use with oesophageal feeding tubes.

Gastrostomy Tube (PEG Tube)

The gastrostomy tube (sometimes called a PEG tube) is placed directly through the cat’s side into the stomach. It normally has to be inserted using a general anaesthetic. This tube is less likely to interfere with the cat’s swallowing mechanism than the oesophageal tube, but neither type seems to bother cats particularly. This tube can also be left in for months.

After the tube is fitted, x-rays should be taken to ensure the tube is in the correct position.

Percutaneous placement of a gastrostomy tube (2009) Armstrong PJ DVM360 explains more about PEG tubes.

PEG tube feeding instructions Stafford D Veterinary Support Personnel Network explains how to feed your cat using a PEG tube.

Naso-Gastric Tube

Occasionally vets use a naso-gastric tube, which can be inserted without anaesthesia. This tube is placed in the nose and runs down to the stomach. Unfortunately, these tubes are narrow so can only be used for liquids, plus they are really only suitable for short-term feeding of several days.

If your cat is given such a tube, the throat can be a little sore for a few days after removal, so you will need to continue to feed smooth, easily swallowed food during this period.

Feeding Tubes Tips

As with assist feeding, you need to feed a decent amount of food, spread over a number of sessions each day.

To prepare the food for the tube, you normally need to blend it with a little water so it does not block the tube. This means you often need to use a strainer. Amazon sell one. Some people also sieve the food after blending it.

You often use a syringe to place food in the tube, see above for more information on the best syringes to buy and sources.

Try not to syringe too much food into the tube at once, but start slowly and build up gradually.

After feeding you should flush the tube with about a teaspoon of water to clean it. You will also need to check the tube every few days to make sure it is not blocked and give it a more thorough cleaning with equipment supplied by your vet.

One advantage of a feeding tube is that you can give water (not the fluids usually used for sub-Qs) orally rather than having to give sub-Qs. Treatment recommendations for CKD in cats (2019) International Renal Interest Society states that they should be considered for Stage 4 cats: "Feeding tubes can be used to administer fluids as well as food." You can also give oral medications via the tube. Conservative medical management of chronic renal failure in the cat (2010) DiBartola SP CVC in San Diego Proceedings states "The clinician should consider placement of a gastrostomy tube in CRF cats with poor appetites because this approach allows convenient delivery of calories, fluids, and medications and the tubes are well tolerated by most cats."  

Feeding Tube Links

Tufts University College of Veterinary Medicine has some helpful FAQs about feeding tubes.

Long Beach Animal Hospital has more information on feeding tubes.

Enteral nutrition: tube feeding (2014) Wara A & Datz C Clinician's Brief Nov 14 pp25-27 discusses feeding tubes.

Enteral feeding in dogs and cats: indications, principles and techniques (2010) Mitchell KD CVC in Kansas City Proceedings explains more about feeding tubes.

All Feline Hospital explains how to use and care for feeding tubes.

Feeding tube placement (1999) Seim HB Presentation to the Waltham Feline Medicine Symposium discusses the pros and cons of the different types of feeding tube.

Exclusively Cats Veterinary Hospital explains more about feeding tube use and maintenance.

Feline Assisted Feeding Group can be worth joining if you have a feeding tube.

Appetite Stimulants

Since it is important that cats eat regularly because of the risk of hepatic lipidosis (see above), vets may sometimes prescribe a medication to stimulate appetite.

However, you should not reach for these alone, because whilst some cats may eat because of these medications, they could still feel horrible; and some cats who have untreated nausea or vomiting will not eat even if given appetite stimulants.

Appetite stimulants often do not work on cats who have completely stopped eating; they tend to be more effective at persuading a cat who is still eating, but not enough, to eat more.

Appetite stimulants may also have side effects. Therefore you should definitely try to treat any possible causes of inappetence (see Index of Symptoms and Treatments, scroll down to Appetite Loss), particularly gastric hyperacidity, and try the other tips mentioned above, rather than only opting for appetite stimulants.

Top five indications for appetite stimulation (2020) Cook AK Clinician's Brief Jun 2020 pp31-35 discusses when to consider using appetite stimulants.

These days you are quite likely to be given mirtazapine in the form of Mirataz but some vets may recommend some of the other treatments discussed below.

• B vitamins

• Mirtazapine (Remeron, Ispin or Mirataz)

• Cyproheptadine (Periactin)

• Cetirizine (Zyrtec)

• Steroids

• Diazepam (Valium)

• Capromorelin (Entyce)

B Vitamins

All CKD cats should be given B vitamins, because they can help prevent anaemia and often act as a mild appetite stimulant.

Pharmacological appetite stimulation: rational choices in the inappetent cat (2014) Agnew W & Korman R Journal of Feline Medicine & Surgery 16(9) pp749-56 says "Cats have a higher requirement for some B  vitamins  when  compared  with  dogs. Experimental depletion of B vitamins results in  anorexia  in  other  species. Supplementation with B vitamins may prevent this occurring, although no evidence exists to confirm this. Still, provision of B vitamins is simple and should be considered in all inappetent cats."

Vitamin B12 in the form of methylcobalamin can be particularly helpful. You can read more about B vitamins here.

Mirtazapine (Mirataz, Remeron or Istin)

In recent years mirtazapine (Remeron in the USA, Zispin in the UK, or Mirataz in either) has become increasingly popular as an appetite stimulant for CKD cats. Mirtazapine is actually an anti-depressant but in small doses it can cause an increase in appetite. It does this via its effects on serotonin receptors, which increase the level of serotonin in the brain, which leads to increased appetite.  It may also have anti-emetic (anti-vomiting) properties through its effects on serotonin receptors in the gastrointestinal tract.

Mirtazapine must be used with caution in those with kidney problems. It should also be used with caution in cats with hyperthyroidism or liver problems.

The main concern with mirtazapine is the small risk of developing a condition called serotonin syndrome. I haven't used mirtazapine for my own cats, but a transdermal version for cats called Mirataz is now approved for use in the USA and Europe, so you may well be offered it. Many people do find mirtazapine helpful and there has been quite a lot of research into its use in cats, including CKD cats, with it being widely used in vet schools. Please be sure to start with a small dose and low frequency (see below) and monitor blood pressure.

Veterinary Partner has information about the use of mirtazapine in cats. It mentions that it may help with nausea as well as appetite.

Net Doctor has some information about the use of mirtazapine in humans.

Medicine Net also has information about the use of mirtazapine in humans.

Mirtazapine and Weight Gain

Mirtazapine seems to be an effective appetite stimulant in cats, which may assist with weight gain. Indeed, Mirataz, the transdermal version of mirtazapine recently approved for use in cats, describes itself as a weight gain medication rather than as an appetite stimulant.

Mirtazapine as an appetite stimulant and anti-emetic in cats with chronic kidney disease: a masked placebo-controlled crossover clinical trial (2013) Quimby JM & Lunn KF Veterinary Journal 197(3) pp651-655 found that "the oral administration of 1.88 mg [⅛ of a 15mg tablet] of mirtazapine every other day for 3 weeks to cats with CKD resulted in significantly increased appetite. Additionally, significant weight gain, increased activity and decreased vomiting were demonstrated."

Double-blind placebo-controlled randomized study of transdermal mirtazapine ointment for the management of feline weight loss (2017) Longpre K, Buhles W, Tin M, Hu T, Quimby J, Labelle D, O’Banion MP, Lee J & Markey S Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1334 looked at the effects of transdermal mirtazapine on weight and found that "Use of 2% MZP resulted in a mean weight gain of 4.07% compared to 0.29% for placebo after two weeks of transdermal treatment."

A double-blind, placebo-controlled, randomized study to evaluate the weight gain drug, mirtazapine transdermal ointment, in cats with unintended weight loss (2019) Poole M, Quimby JM, Hu T, Labelle D & Buhles W Journal of Veterinary Pharmacology and Therapeutics 42(2) pp179-188 looked at the use of 2.mg transdermal mirtazapine in cats who had experienced weight loss. The study concludes "Application of mirtazapine transdermal ointment was well tolerated both topically and systemically and resulted in significant weight gain in cats experiencing unintended weight loss associated with various underlying diseases."

Mirtazapine Formulations and Availability

Mirtazapine is available as tablets and in some countries in transdermal form:

Mirtazapine Tablets

Mirtazapine is widely available in 15 mg tablet form, and many people have used these, cut into the appropriate size (in most cases, people give ⅛ of a tablet, but see below).

In the USA you should also be able to find 7.5mg tablets at pharmacies such as Costco. They are also available from VetRXDirect.

At one point 2 mg tablets were available in several countries (including Canada and the UK) for use in cats, though these seem to have largely disappeared.

Mirtazapine Transdermal

Mirataz is a transdermal form of mirtazapine in cat-sized doses which was approved by the FDA in May 2018 and which became available in the USA in July 2018. This follows a series of clinical trials (see below) into the use of mirtazapine in this form, though not all of the trials used Mirataz.

Mirataz received regulatory approval in Europe in early 2020 and regulatory approval is being sought in other countries throughout the world.

It was previously possible to obtain transdermal mirtazapine from a compounding pharmacy in the USA, but this is no longer legal now Mirataz has received regulatory approval.

VetRXDirect sells Mirataz for US$30.

Mirtazapine Dosage: Amount and Frequency

There has been a lot of debate over the years about how much mirtazapine to give to a CKD cat and how often. The dosage and frequency may vary depending upon whether you are using tablets or the transdermal form.

Mirtazapine Tablets: Amount

It used to be common to give CKD cats 1.88 mg to 3.75 mg (⅛ to ¼ of a 15 mg tablet) of mirtazapine every three days. This worked well for many cats, but caused problems for some others.

Mirtazapine toxicity in cats: retrospective study of 84 cases (2006-2011) (2015) Ferguson LE, McLean MK, Bates JA & Quimby JM Journal of Feline Medicine & Surgery 28(11) pp868-874 examined the records from the ASPCA's Animal Poison Control Center. It found that a dose of 3.75mg was associated with signs of toxicity in 25 of the 84 cats in the study. The study concludes: "The greater number of adverse effects at 3.75 mg rather than 1.88 mg suggests that the latter may be a more appropriate starting dose for stimulating appetite while limiting toxicity."

Plumb's Veterinary Drug Handbook (2015) also recommends starting with the 1.88 mg (⅛ of a 15 mg tablet).

If you are using tablets, I would therefore suggest starting with the lower dose of 1.88mg  (⅛ of a 15 mg tablet).

Mirtazapine Tablets: Frequency

The original dosing frequency for cats was only once every three days.

Mirtazapine tablets usually take effect pretty quickly, within a couple of hours, though they do work more slowly for some cats. However, there has been a lot of debate about how long mirtazapine in tablet form lasts for and how often it can be given, particularly since, like cyproheptadine below, it appears that mirtazapine may become less effective for some cats over time, and therefore only being able to give the medication every three days could be problematic.

A study at Colorado State University, The pharmacokinetics of mirtazapine in cats with chronic kidney disease and in age-matched control cats (2011) Quimby JM, Gustafson DL & Lunn KF Journal of Veterinary Internal Medicine 25(5) pp985-9, found that the half life of the drug in tablet form (the time it takes for 50% of the medication to leave the body after taking it) was shorter than originally thought and that therefore a 48 hour dosing interval was acceptable.

The Veterinary Teaching Hospital at Colorado State University has been prepared to give mirtazapine daily if required, particularly to late stage cats. Single dose pharmacokinetics following transdermal and oral administration of mirtazapine 2% transdermal ointment in cats (2017) Mason B, Buhles W, Quimby J, Labelle D, Jung D, O’Banion MP, Lee J & Markey S Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1334 looked at the effectiveness of oral versus transdermal mirtazapine. It found that absorption of oral mirtazapine "was faster and more consistent" than the transdermal form. It also found that transdermal mirtazapine had a much longer half-life (the time needed until the body clears half of the amount given, leaving 50% still in the body) of 26.8 hours versus 10.1 hours for the tablet form.

In light of this finding, i.e., since half the amount given has left the body after only ten hours, it is possible that daily dosing of mirtazapine will become more prevalent. Mar Vista Vet says that mirtazapine tablets work best when a smaller dose is given daily. However, because of the risk of serotonin syndrome, it is wise to start with an every three day dosing schedule, only increasing the frequency if necessary and of course with your vet's agreement.

Mirtazapine Transdermal (Mirataz)

There has been some research in recent years into the use of transdermal mirtazapine in cats and a commercial cat-sized version called Mirataz became available in the USA in July 2018 (see above) for the management of feline weight loss.

Mirataz was developed by a company called KindredBio, working in conjunction with Dr Jessica Quimby. In March 2020 KindredBio announced that Mirataz had been sold to Dechra Pharmaceuticals plc in the UK for US$43M plus a share in the profits from ongoing sales. The sale was completed in April 2020.

Dechra plans to launch Mirataz in the UK and Europe, followed by other international markets. The European Medicines Agency stated in January 2020 that Mirataz is already approved in the EU, and the approval process is being undertaken in other markets.

Mirtazapine Transdermal (Mirataz) Amount and Frequency

Mirataz recommends applying a 1.5 inch "ribbon" of the ointment to the inner pinna (top part) of the cat's ear, which it says is roughly 2mg, equivalent to 1ml. You should wear gloves when applying the ointment. It advises doing this once daily for fourteen days.

People using other forms of compounded transdermal mirtazapine (which is no longer legal in the USA) seem to use the same dose as those giving tablets.

Mirtazapine Research

Drug exposure and clinical effect of transdermal mirtazapine in healthy young cats: a pilot study (2017) Benson KK, Zajic LB, Morgan PK, Brown SR, Hansen RJ, Lunghofer PJ, Wittenburg LA, Gustafson DL, Quimby JM Journal of Feline Medicine and Surgery 19(10) pp998-1006 looked at the use of transdermal mirtazapine in healthy cats and found that "the dose required is likely much larger than what is generally given orally. A consequence of this higher dose was an increased incidence of agitation and other negative effects."

A slightly later study, Safety of mirtazapine 2% transdermal ointment administered topically to cats at 5mg/kg for 28 days (2017) Avenatti A, Buhles W, Quimby J, Labelle D, O’Banion MP Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1333, examined the effects of doses much higher than typically used, in both healthy cats and two CKD cats (one in Stage 1, one in Stage 2, but both much younger than most CKD cats), given for 28 days.  Many of the cats developed irritated ears where the medication was applied, and one of the CKD cats had a week of vomiting which resolved without treatment. There were no changes in bloodwork or blood pressure in any of the cats, and they did all gain weight. The study concludes "Mirtazapine 2% transdermal ointment was well tolerated in cats when administered at 5 mg/kg for 28 consecutive days."

Single dose pharmacokinetics following transdermal and oral administration of mirtazapine 2% transdermal ointment in cats (2017) Mason B, Buhles W, Quimby J, Labelle D, Jung D, O’Banion MP, Lee J & Markey S Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1334 looked at the effectiveness of oral versus transdermal mirtazapine in healthy cats. It found that absorption of oral mirtazapine "was faster and more consistent" than the transdermal form. It also found that transdermal mirtazapine had a much longer half-life (time until the body cleared half of the amount given, leaving 50% still in the body) of 26.8 hours versus 10.1 hours for the tablet form. This may mean that it is appropriate to give transdermal mirtazapine less frequently than the oral version, though that is in fact not the recommended dosing schedule for Mirataz.

This may be because of another paper, Multiple dose pharmacokinetics of mirtazapine 2% transdermal ointment in cats (2017) O’Banion MP, Buhles W, Quimby J, Labelle D, Jung D, Jung D Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1335, which concluded "After once daily dosing for 14 days, mirtazapine 2% transdermal ointment achieves clinically relevant serum concentrations in cats."

Safety of mirtazapine 2% transdermal ointment administered topically to cats at 5 mg/kg for 28 days (2017) Avenatti A, Buhles W, Quimby JJ, Labelle D & O’Banion MP Journal of Veterinary Internal Medicine (2017 ACVIM Forum Research Abstract Program) 31(4) p1333 states "Mirtazapine 2% transdermal ointment (2% MZP) achieves clinically relevant serum concentrations in cats and results in increased body weights at a dose of 0.5 mg/kg." The study looked at the safety of giving higher dosages (2mg/kg) to both healthy cats and CKD cats, and concluded "Mirtazapine 2% transdermal ointment was well tolerated in cats when administered at 5 mg/kg for 28 consecutive days."

Assessment of compounded transdermal mirtazapine as an appetite stimulant in cats with chronic kidney disease (2020) Quimby JM, Benson KK, Summers SC, Saffire A, Herndon AK, Bai S & Gustafson DL Journal of Feline Medicine and Surgery 22(4) pp376-383 looked at the use of compounded transdermal mirtazapine (not Mirataz) in cats in Stage 2 or 3 CKD. The dosages used were 1.88 mg/0.1ml every other day or 3.75mg/0.1ml. Both strengths led to an increase in appetite, food intake and weight, but an increase in BUN was also seen. Some of the cats exhibited excessive howling. .

Mirtazapine Side Effects

As a tetracyclic anti-depressant, mirtazapine may cause an increase in blood pressure and heart rate, although Plumb's Veterinary Drug Handbook says that it may cause orthostatic hypotension so should be used with caution in patients with heart problems. It may increase cholesterol levels. Some members of my support group have seen increased urination.

Occasionally you may see reduced white blood cells.

Like cyproheptadine, it may make some cats restless, agitated and vocal (to such an extent in some cases that it is known on Tanya's CKD Support Group as meowzapine), although around 50% of human patients on mirtazapine feel sleepy.

In some cases, you may see a severe reaction known as serototin syndrome (see below).

Mirataz says Mirataz should be used with caution in cats with kidney disease.

Mirtazapine and Serotonin Syndrome

In 2007 I heard from a lady whose CKD cat had an extremely severe reaction to mirtazapine, and her cat's reaction lasted for around three days. A poison centre was unable to offer any suggestions, so she just had to wait for the drug to work its way out of her cat's system.

I subsequently learnt that when cats react badly to mirtazapine, it is often because their bodies are creating too much of a neurotransmitter called serotonin. As explained above, mirtazapine works via its effects on serotonin receptors. Mirtazapine is supposed to stop serotonin being bound to receptors in nerve cells, which leads to increased levels of serotonin in the brain, which then in turn leads to increased appetite  Unfortunately, if too much serotonin accumulates in the cat's brain, it can lead to a condition called serotonin syndrome. Although this reaction is not common, I have since heard from several other people whose cat experienced it, and this is probably because, as Serotonin syndrome (2013) Almgren CM & Lee JA Clinician's Brief Oct 15 pp11-15 states, the risk is higher in CKD patients. Therefore please be aware of the possibility, and be sure to start with a really small dose as outlined above.

Drugs says that using ondansetron (a nausea treatment) and mirtazapine together may increase the risk of serotonin syndrome.

Mar Vista Vet mentions that the risk of serotonin syndrome is higher if you are using a painkiller called tramadol at the same time.

Symptoms of serotonin syndrome include a fast heart rate, hypertension (including dilated pupils), excessive vocalisation (meowing loudly or howling), being "spaced out", walking strangely, stumbling, pacing up and down, breathing problems such as panting or breathing very fast, increased body temperature and agitation. You may see some of these symptoms to a lesser degree in any cat on mirtazapine (we don't call it meowzapine for nothing) but the degree of the symptoms is what matters.

Serotonin syndrome (2013) Almgren CM & Lee JA Clinician's Brief Oct 15 pp11-15 states that "untreated, serotonin syndrome can result in death." Please don't panic, that paper is talking about serotonin syndrome generally, including cases of cats and dogs who have accidentally eaten human-sized doses of mirtazapine or other medications. To date I have not heard of any cat given a cat-sized dose of mirtazapine who has died. However, I would certainly recommend contacting your vet if you think your cat has serotonin syndrome, and you might feel safer taking your cat to the vet.

The antidote for serotonin syndrome caused by mirtazapine is actually another drug commonly used as an appetite stimulant in cats, cyproheptadine. Treatment of the serotonin syndrome with cyproheptadine (1998) Graudins A, Stearman A & Chan B The Journal of Emergency Medicine 16(4) pp615-9 explains more about this. One possible dose would be 2mg given twice within the first 24 hours, followed by 1 mg given twice daily for the next 48 hours; but do not give this without your vet's knowledge and approval. Depending upon the severity of your cat's case, additional treatments such as IV fluids or inducing vomiting may also be necessary.

Try not to worry too much. All the cats I have heard about with serotonin syndrome were back to normal within a few days. Mirtazapine toxicity in cats: retrospective study of 84 cases (2006-2011) (2015) Ferguson LE, McLean MK, Bates JA & Quimby JM Journal of Feline Medicine & Surgery 18(11) pp868-874 found that "For cats with available information, the onset of clinical signs ranged from 15 mins to 3 h, and resolution of clinical signs ranged from 12-48 h." So any problems should be resolved within 12 hours to a maximum of two days.

Serotonin syndrome (2013) Volpi-Abadie J, Kaye AM & Kaye AD The Ochsner Journal 13(4) pp533–540 explains more about serotonin syndrome generally.

Mirtazapine Interactions

Most people I have heard from have not had problems with mirtazapine, but I have heard from a couple of people whose cats were on treatment for hyperthyroidism who did not seem to do well on mirtazapine. This is probably because, as mentioned by The University of Maryland Medical Center, methimazole, a commonly used medication for hyperthyroidism, reduces levels of a liver enzyme called CYP2D6 which helps to clear mirtazapine from the body. If your cat is on methimazole and you want to use mirtazapine, I would talk to your vet about using a reduced dose of mirtazapine.

Drugs says that using ondansetron (a nausea treatment) and mirtazapine together may increase the risk of serotonin syndrome.

Mar Vista Vet mentions that the risk of serotonin syndrome is higher if you are using a painkiller called tramadol at the same time.

Plumb's Veterinary Drug Handbook states that mirtazapine should not be used in cats who have taken selegiline in the last fourteen days.

Cyproheptadine (Periactin)

Cyproheptadine (Periactin) is an antihistamine which in cats may have the side effect of stimulating appetite. It has historically been a popular choice, and I have used it in my own cats.  

Since cyproheptadine is not really designed to be an appetite stimulant (and indeed may not work for all cats), dosage can be rather hit and miss, so you should be guided by your vet. Since the body of a cat with CKD eliminates cyproheptadine more slowly than that of a healthy cat, it is best to start with a low dose, increasing it only if necessary — you are aiming for a dosage which stimulates your cat to eat whilst minimising the chance of side effects.

Unfortunately cyproheptadine can also have several side effects, such as causing agitation (often accompanied by howling), making the cat breath faster, or having the opposite effect of causing lethargy. In a small number of cats it may cause reduced urination or an increased heart rate or temperature. If you see such symptoms, check with your vet because the dosage you have used could well be too high for your particular cat.

Cyproheptadine comes in 4mg tablets. Whilst Plumb's Veterinary Drug Handbook mentions a dose of 1 - 4mg once or twice a day for a cat, many people on Tanya's CKD Support Group have found a dose of 0.5mg once per day works well and also seems to reduce the risk of the side effects mentioned above. Therefore you may wish to ask your vet if you can start at this level, increasing it only if necessary. 

According to one study, Disposition of cyproheptadine in cats after intravenous or oral administration of a single dose (1998) Norris CR, Boothe DM, Esparza T, Gray C, Ragsdale M, American Journal of Veterinary Research 59(1) pp79-81, you may need to give cyproheptadine for approximately 2.5 days before it reaches a steady level in the cat, but some people have found that even one dose can take effect pretty quickly. Once the cat has been on cyproheptadine for a few days, it should certainly take effect within a couple of hours, although some cats develop appetite within 15 minutes, so be sure to have fresh food ready for your cat.

You may choose to use cyproheptadine for a few days and then see if you can manage without it, but if you find you need to use it on a longer-term basis, this appears to be safe, though its effectiveness may gradually reduce, and the cat may sneeze as the effects wear off. If you use cyproheptadine longer term, monitor BUN levels (which you are probably doing anyway), because these may occasionally increase when using cyproheptadine.

Mar Vista Vet mentions that cyproheptadine "is best avoided in patients with glaucoma, recovering from urinary blockage, and heart failure patients."

Cyproheptadine is available in Canada and the UK without a prescription, which is cheaper than buying it from your vet, but please do not use it on your cat without your vet's knowledge and approval.  

Cyproheptadine Interactions and Side Effects

Cetirizine (Zyrtec)

Like cyproheptadine, cetirizine is an antihistamine, and therefore vets regularly prescribe it for allergies. An open clinical trial on the efficacy of cetirizine hydrochloride in the management of allergic pruritus on cats (2012) Griffin JS, Scott DW, Miller WH & Tranchina MM Canadian Veterinary Journal 53(1) pp 47–50 reports on its use for allergic itch and states that "no adverse side effects were reported."

I have not heard of any vet prescribing cetirizine as an appetite stimulant, but a number of people on Tanya's Support Group have found it does seem to be an effective appetite stimulant for some CKD cats.

Cetirizine is widely available under the brand name of Zyrtec or as a generic. Make sure you do not buy Zyrtec D by mistake, because, as mentioned by Veterinary Partner, this also contains pseudoephedrine, which is not suitable for cats.

Although cetirizine is available over the counter, do not use it without talking to your vet first because it has not been widely tested in cats, and as far as I know, it has never been tested in CKD cats.

Why I love Zyrtec for cats (2010) is an article by Dr P Khuly.

Cetirizine Dosage

Cetirizine is usually available in 5mg or 10mg tablets, and is dosed once daily. As with the other medications used as appetite stimulants, start at a low dose and only increase if necessary. Here are some of the dosages seen on my support group:

• People often start with 1.25mg daily (one eighth of a 10mg tablet or one quarter of a 5mg tablet).

• If this doesn't work, your cat may need 2.5mg (one quarter of a 10mg tablet or one half of a 5mg tablet) daily.

• Some cats require 5mg once daily (half of a 10mg tablet or one 5mg tablet).

Be guided by your vet as to the best dose for your cat.

Cetirizine Side Effects

Drugs points out that since cetirizine is excreted mainly via the kidneys, "Patients with renal and/or liver disease may be at greater risk for adverse effects from cetirizine due to decreased drug clearance." It adds that the manufacturer recommends a dosage reduction for humans with reduced kidney function.

Pet Place states "The most common adverse effects of cetirizine are sedation, lethargy, vomiting, drooling  (hypersalivation), and lack of appetite" (yes, the opposite of what you are trying to achieve).

Steroids (as Appetite Stimulants)

Your vet may offer you a steroid if your cat is not eating very much. There are two classes of steroids, corticosteroids and anabolic steroids, and both may help stimulate appetite.

However, corticosteroids can have serious side effects with long-term use (including triggering diabetes, fluid retention and resulting hypertension, and masking infections), and may also increase stomach acid, which is not ideal for a CKD cat. In one study, some cats developed a unique form of congestive heart failure seven days of starting steroids.

Drugs warns that Winstrol-V may cause severe liver disease in cats. In Medical management of chronic kidney disease in cats (2015) Dr S DiBartola says "The use of anabolic steroids (e.g., stanozolol) in CKD is empirical and their efficacy remains to be documented. The margin of safety for the commonly used anabolic steroid, stanozolol in cats is narrower than in dogs and it may result in hepatotoxicity characterized by hepatic lipidosis and cholestasis with minimal hepatocellular necrosis. Thus, use of anabolic steroids in cats with CKD is not recommended."

Thomas took anabolic steroids whilst he had CKD. He received a monthly shot at the vet's. We were able to reduce Thomas's steroid dose, but he still seemed to do better overall when he was taking his steroids. 

Diazepam (Valium)

Diazepam (Valium), a tranquilliser and muscle relaxant, is sometimes used as an appetite stimulant. Diazepam has a number of side effects, including affecting depth perception which can be dangerous for cats allowed outdoors. It may also cause ataxia (loss of co-ordination or an unsteady walk). In some cases, although it is a tranquilliser, diazepam may have the paradoxical effect of causing aggression.

The main problem with diazepam is that unfortunately a small number of cats develop acute liver failure after several days of use, so if you do choose to use this drug, your vet should check your cat’s liver values before starting it and a few days afterwards. Fulminant hepatic failure associated with oral administration of diazepam in 11 cats (1996) Center SA, Elston TH, Rowland PH, Rosen DK, Reitz BL, Brunt JE, Rodan I, House J, Bank S, Lynch LR, Dring LA & Levy JK Journal of the American Veterinary Medical Association 209 pp618-25 reports on the risks of using diazepam in cats, and concludes that some cats have an idiopathic (i.e. the precise reason is unknown) response to this medication. Some cats just appear to be sensitive to it, and it is hard to know beforehand which cats would react in this way.

Pharmacological appetite stimulation: rational choices in the inappetent cat (2014) Agnew W & Korman R Journal of Feline Medicine & Surgery 16(9) pp749-56 says "The use of oral benzodiazepines is controversial in cats due to multiple reports of serious, and almost invariably fatal, idiosyncratic hepatotoxicity observed 5–13 days after the use of oral diazepam. These drugs are reportedly either contraindicated, or only to be  used  with  caution/at  reduced  rates,  in patients  with  hepatic  dysfunction. Caution is also required in patients with renal disease. As  viable,  effective  alternatives exist, the use of these drugs has largely been superseded."

Cimetidine (Tagamet) may increase the effects of diazepam, so it would probably be safer to use famotidine (Pepcid AC) or ranitidine (Zantac) instead.

Mar Vista Vet has more information on using diazepam in cats, including a comment that diazepam may have a stronger effect if used at the same time as cimetidine (Tagamet); and it may heighten the effect of Digoxin, a heart medication.

Pet Place discusses the pros and cons of using diazepam.

Wedgewood Pharmacy has recommended that diazepam should be used with caution in animals with decreased kidney function.

Although some people have had good results with diazepam, I personally would not risk it; if you choose to use it, I would suggest you do so as a last resort.

Capromorelin (Entyce)

Capromorelin (Entyce) is a ghrelin receptor agonist made by Aratana Therapeutics which has been approved by the US Food and Drug Administration for the stimulation of appetite in dogs. It works by mimicking ghrelin, often called the hunger hormone because it sends messages to the brain telling it you are hungry and thus triggering appetite. Capromorelin: a ghrelin receptor agonist and novel therapy for stimulation of appetite in dogs (2018) Rhodes L, Zollers B, Wofford JA & Heinen E Veterinary Medicine and Science 4(1) pp3–16 explains more about how it works.

Capromorelin became commercially available in the USA in October 2017, in 10 mL, 15 mL and 30 mL bottles. It is normally given once daily.

Capromorelin is not currently approved for use in cats but Animal Pharm News reported (July 2015) that a placebo-controlled trial into the use of capromorelin in cats showed promising results and it was hoped that it might be approved for use in cats in 2018; this did not happen. The manufacturer is also considering seeking approval for the product in the EU.

It should be used with caution in patients with kidney disease. A couple of  members of Tanya's CKD Support Group have tried capromorelin in their CKD cats, but reports thus far are disappointing, with members stating it did not seem to really help with appetite but did seem to cause lethargy. This is a known side effect in cats: Evaluation of the safety of daily administration of capromorelin in cats (2018) Wofford JA, Zollers B, Rhodes L, Bell M & Heinen E Journal of Veterinary Pharmacology and Therapeutics 41(2) pp324-333 reports on the results of safety studies and states that side effects seen included lethargy  Other side effects that were seen were vomiting, drooling, headshaking and lipsmacking.

Dr Justine Lee discusses capromorelin and has a photo of the product.

Drugs has some information on capromorelin.

Thomas and Indie indulging in their favourite hobby!

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This page last updated: 11 November 2020

Links on this page last checked: 19 June 2020

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TREATING YOUR CAT WITHOUT VETERINARY ADVICE CAN BE EXTREMELY DANGEROUS.

I have tried very hard to ensure that the information provided in this website is accurate, but I am NOT a vet, just an ordinary person who has lived through CKD with three cats. This website is for educational purposes only, and is not intended to be used to diagnose or treat any cat. Before trying any of the treatments described herein, you MUST consult a qualified veterinarian and obtain professional advice on the correct regimen for your cat and his or her particular requirements; and you should only use any treatments described here with the full knowledge and approval of your vet. No responsibility can be accepted.

If your cat appears to be in pain or distress, do not waste time on the internet, contact your vet immediately.

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