Am I being selfish and unkind?

"Kate" wrote in message
...
Our little old boy (now 16 and a half) was diagnosed with hyperthyroidism
last January. Unfortunately, he also had underlying CRF and when he was
given medication for the hyperT his kidneys couldn`t take it. We tried
different drugs and dosages, but each time he started vomiting and his BUN
and creatinin levels rose alarmingly. Reluctantly, we took the decision to
stop treating the hyperT, and just give him Fortekor to help his kidneys.
Amazingly he is still with us, although he has lost over half his body
weight and looks dreadful. Up until recently he was eating a fairly
reasonable amount and his weight loss slowed down. We have been giving him
Hills A/D almost exclusively, mainly because that was all he would eat,
and also I because I thought that as his appetite was small, the A/D would
provide enough calories to maintain him. However, his appetite has now
dropped away and although he seems to want to eat, nothing I give him
tempts him. The vet says that he is undoubtedly feeling nauseous, and
from the way he turns his head away when he sniffs my latest offering, I
think this must be the case. Anabolic and cortico steroid injections
haven`t helped and he is now very weak and tends to totter when he walks.
He will take a few steps and then sit down, and this morning he lost his
balance on our hard kitchen floor and fell over. He got up very quickly,
though, and he does still have the strength to jump on to our knee for a
cuddle. I look at him and think that it is time to say goodbye, but he is
still chirpy and doesn`t seem depressed as if he is in pain - he is just
very, very tired. It doesn`t seem right that I wait until he is in pain,
and yet, if he is still enjoying his little comforts, as he seems to be,
it doesn`t seem right to put him down too soon.

I am in such a quandary that I would welcome your views, please.

Kate


Just my opinion but if the cat is feeling sick, there is no reason to
believe he ever will feel better, and all reasonable treatment options have
been exhausted then it is no longer too early.

W

"Kate" wrote in message
...
Thank you for replying, Phil. Back in January I did post here asking
for advice when Toby was first diagnosed, and you were kind enough to
suggest the regime you recommend below. We did try all of your
suggestions, including the sub-therapeutic dose of methimazole.
Unfortunately, even with that tiny dose, Toby vomited.


Vomiting is the most common adverse effect of oral methimazole. The
transdermal gel formulation reduces if not eliminates this effect in most
cats because the drug is absorbed through the skin (earflap) rather than the
digestive tract. I strongly suggest you speak to your vet about the
transdermal gel and at least try it.

There's also another version of methimazole called 'carbimazole'. This drug
produces much fewer and milder side effects than methimazole- about 4% as
opposed to 20% for methimazole. Carbimazole must be obtained from a
compounding pharmacy because its not available in the US commercially due to
trade agreements with Lilly, but it might be commercially available in the
UK.

There are also two more alternatives to methimazole that produce virtually
*no* adverse effects: iopanoic acid (Telepaque) and diatrizoate sodium
(Hypaque). Telepaque was discontinued by the manufacturer last year but is
still available from a compounding pharmacy. Hypaque is also available only
from a compounding pharmacy and is a little less expensive than Telepaque.
I would certainly speak to your vet about these alternatives as soon as
possible.


We tried him on
the k/d diet, but he wouldn`t eat it and the vet told me that not
eating was worse than eating the "wrong" thing. I think the fact that
he wasn`t diagnosed early enough may have caused his kidneys to become
used to the high blood throughput for too long.


You have a good point. Actually, hyperthyroidism could contribute to the
progression of or even predispose cats to CRF. The increased renal blood
flow and increased filtration rate (glomerular filtration rate [GFR] caused
by hyperthyroidism results in glomerular hyperfiltration. Glomerular
hyperfiltration may be initially beneficial because it keeps the BUN/Cr
down, but it can eventually damage functional nephrons and lead to
progressive deterioration of renal function. So, by trying to find a
treatment for his hyperthyroidism that he can handle, might actually slow
the progression of his CRF.




Thinking back, I am
pretty sure that Toby had hyperT in September 2004, but the vet we
went to then did not pick up on it. It was only when he continued to
lose weight (the only symptom, BTW) and I sought a second opinion that
he was diagnosed.


Too many vets rely on an ravenous appetite with weight loss as a diagnosis
of hyperthyroidism. Some hyperthyroid cats have another form of
hyperthyroidism termed 'Apathetic Hyperthyroidism' in which cats develop
inappetence or even complete an*orexia. Some hyperthyroid cats even have
*normal* T4 levels because an underlying disease is falsely suppressing T4
levels. The Free T4 by Equilibrium Dialysis assay was developed to detect
hyperthyroidism in cats with normal T4 levels. I'm very happy you sought a
second opinion.





I shall certainly ask our vet about the appetite stimulant you
mentioned. Anabolic steroid injections did help for a few weeks and
his weight stabilised, but then they seemed to lose their efficacy and
the weight loss began again. I think that now he is almost at the
lowest limit he can be before organs start packing up; he has a very
large frame and in his prime weighed in at just over 6 kg of muscle
and bone. He is now down to 2.9 kg. He has surprised us all several
times this last 9 months or so by perking up ("bouncing back" is going
too far!) but I fear that we have now gone passed the point of no
return. I know that cats a very good at masking pain, as Sherry said,
but although I believe he cannot be comfortable, especially if he is
nauseous, he isn`t vomiting and doesn`t crouch hunched up and looking
miserable, so perhaps I can postpone the inevitable for a little
longer. But is it selfish and unkind of me to wait until he _is_ in
pain and miserable? That`s my dilemma.


I think you just need to find the right therapy for him. Hyperthyroidism
affects every cell in every organ in every organ system in the body. I got
a feeling he'll bounce right back again once his hyperthyroidism is brought
down to an acceptable level. I've seen cats that were literally on death's
doorstep, bounce back after their hyperthyroidism was brought under control.
That's why I'm encouraging you to pursue the alternatives I mentioned above.



Thanks for listening.

Kate

I understand how you feel. I know I would second guess my decision if I
didn't at least try as many alternatives as reasonably possible. The doubt
would haunt me for the rest of life.

Keep the faith,

Phil




"Phil P." wrote in message
...

"Kate" wrote in message
...
Our little old boy (now 16 and a half) was diagnosed with
hyperthyroidism last January. Unfortunately, he also had
underlying
CRF and when he was given medication for the hyperT his kidneys
couldn`t take it. We tried different drugs and dosages, but each
time
he started vomiting and his BUN and creatinin levels rose
alarmingly.
Reluctantly, we took the decision to stop treating the hyperT,

Hyper-T/CRF is very difficult combination to manage- but it can be
done-
been there. I don't think you should stop treating his
hyperthyroidism
because that could kill him sooner than CRF- i.e., develop
congestive heart
failure associated with thyrotoxic heart disease.

You said you tried different doses of methimazole. Did you try
very small
sub-therapeutic doses such as 1.25 mg? A gradual decrease in serum
T4 will
result in a more gradual change in renal blood flow- which will
allow better
autoregulation of the kidneys. IOW, his BUN/Cr will not rise
dramatically
or abruptly. The slower and more gradual the better the results.
The
dosing schedule I followed was: 1.25 mg/once a day for 3-5 days;
then 1.25
mg/twice a day for 5 days; then 1.25 mg AM/2.5 mg PM for 3-5 days.
If he
tolerates that dose then 2.5 mg/twice a day. If his therapeutic
dose is
greater than 5 mg/day, increase the dose by 1.25 mg AM for 3-5 days
then by
1.25 mg PM.

You may not be able to control both diseases but you should be able
to
strike a delicate balance between an "acceptable" level of
hyperthyroidism
and an "acceptable" level of azotemia. The smaller and slower the
increases the better the chances of striking an "acceptable" balance
of both
diseases.

If you're dosing him with methimazole, you might want to cut the
pill in
half and put it in a #2 or #3 gelcap. Methimazole is very bitter and
causes
many cats to lose their appetite. Encasing the pill in a gelcap
will mask
the taste and smell and has no effect on absorption. Methimazole is
also
available in a transdermal gel that's applied to inner earflap
(pinna).

Also, you should be able to reduce his azotemia by feeding a food
with a
lower protein content (g/d-k/d) since the by-products of protein
catabolism
significantly contributes to the BUN. You should be able to
stimulate his
appetite enough to eat g/d with cyproheptadine (Periactin). The
usual dose
for cats is 2 mg (1/2 tab) twice a day- but CRF cats eliminate the
drug
slower than cats with healthy kidneys- so, your vet will probably
adjust the
dose based on response.

Managing these diseases simultaneously can be difficult and
frustrating--
but it can be done. Seems to me that you'd welcome the extra effort
to save
your little guy.

Keep the faith.

Best of luck,

Phil.

We did try carbimazole after his poor response to methimazole. (Here
in the UK vets are not allowed to prescribe the human-approved form
until the vetinerary one has been tried.) Toby`s BUN/Cr rose as
dramatically with it as it did with methimazole and he still vomited.
We even tried a sub-therapeutic dose, but he vomited again. However,
we haven`t tried the gel form of methimazole, nor the other two
alternatives you mentioned, so at the first opportunity (the practice
closes at the weekend except for emergencies) I shall be asking the
vet if they are available here, as well as the appetite stimulant.
Meanwhile, Toby is having one of his worse-than-usual days, won`t eat
and looks very moribund. I keep having to check to see if he is still
breathing! The vet has remarked that cats like Toby are very high
maintenance, both financially and emotionally, and I feel a nervous
wreck after all these months.

Your description of "Apathetic Hyperthyroidism" fits exactly with
Toby`s symptoms, BTW, Phil. I wish he was a more typical example of a
hyperT sufferer. Then he wouldn`t be starving himself to death. I
have occasionally force-fed him with a syringe to give his stomach
something to work on, as it will be sore if it is left empty for too
long and so discourage him from eating all the more (do cat`s suffer
from gastritis?). I have to be very careful though, and not push it
too far back in his mouth as the vet warned me that, in his weakened
condition, his swallowing reflex will be slower and he could choke.
It does seem to help, as fairly soon after a force-feed, he will eat
of his own accord. Don`t laugh, but sometimes I feed him from a
teaspoon to save him the bother of sitting up or getting out of bed!
He`s such a daft dollop that I think he forgets there is food
available nearby - or he can`t be bothered to go and get it.

My thanks to everyone who has replied and for your advice and good
wishes.

Kate

"Phil P." wrote in message
...

Vomiting is the most common adverse effect of oral methimazole. The
transdermal gel formulation reduces if not eliminates this effect in
most
cats because the drug is absorbed through the skin (earflap) rather
than the
digestive tract. I strongly suggest you speak to your vet about the
transdermal gel and at least try it.

There's also another version of methimazole called 'carbimazole'.
snip
There are also two more alternatives to methimazole that produce
virtually
*no* adverse effects: iopanoic acid (Telepaque) and diatrizoate
sodium
(Hypaque). Telepaque was discontinued by the manufacturer last year
but is
still available from a compounding pharmacy. Hypaque is also
available only
from a compounding pharmacy and is a little less expensive than
Telepaque.
I would certainly speak to your vet about these alternatives as soon
as
possible.
snip
Some hyperthyroid cats have another form of
hyperthyroidism termed 'Apathetic Hyperthyroidism' in which cats
develop
inappetence or even complete an*orexia.
snip
Phil

"Kate" wrote in message
...
We did try carbimazole after his poor response to methimazole. (Here
in the UK vets are not allowed to prescribe the human-approved form
until the vetinerary one has been tried.) Toby`s BUN/Cr rose as
dramatically with it as it did with methimazole and he still vomited.
We even tried a sub-therapeutic dose, but he vomited again. However,
we haven`t tried the gel form of methimazole,

I think (hope) you might have better luck with the gel since it doesn't go
through the digestive track.

The gel comes in syringes- usually 2.5 mg/0.1 ml (or whatever strength the
vet prescribes). The syringes are clearly marked, so, its very easy to
apply smaller doses if necessary. You must wear an exam glove or finger
cover so you don't absorb any methimazole through your skin. I prefer the
finger cover so the cat can still feel my touch. This is what the syringes
filled with methimazole and finger covers look like:

http://www.maxshouse.com/Drugs/tapaz...nger_cover.jpg

If Toby isn't cooperative, you might find it easier to apply the methimazole
to your finger (w/cover) and then apply it to the inside of his earflap
instead of applying it directly on his earflap. You must rub it in for
about 30-45 secs. and wipe off the ear about 20 minutes later. Keep your
other cats away from him so they don't lick his ear.



nor the other two
alternatives you mentioned, so at the first opportunity (the practice
closes at the weekend except for emergencies) I shall be asking the
vet if they are available here, as well as the appetite stimulant.


The appetite stimulant might help him accept a renal diet- which should help
keep his BUN/Cr. down when the thyroid med slows down his GFR.



Meanwhile, Toby is having one of his worse-than-usual days, won`t eat
and looks very moribund.

You might want to speak to your vet about Abbott Clinicare RF. Its a liquid
renal diet that's easily fed by syringe. Some cats lap it up from a bowl.
You can even get flavoring for it that doesn't affect the nutrient balance.
Getting some nourishment into him might encourage him to eat.



I keep having to check to see if he is still
breathing! The vet has remarked that cats like Toby are very high
maintenance, both financially and emotionally, and I feel a nervous
wreck after all these months.


Having gone through similar situations, I think I know how you feel. Your
dedication is truly admirable.




Your description of "Apathetic Hyperthyroidism" fits exactly with
Toby`s symptoms, BTW, Phil. I wish he was a more typical example of a
hyperT sufferer. Then he wouldn`t be starving himself to death. I
have occasionally force-fed him with a syringe to give his stomach
something to work on, as it will be sore if it is left empty for too
long and so discourage him from eating all the more (do cat`s suffer
from gastritis?).


Yes- cats can have gastritis but the real danger is hepatic lipidosis (fatty
liver syndrome) if he doesn't eat. So, its very important to get food into
him. Anorexia is self-perpetuating in cats- the longer he doesn't eat the
more difficult it becomes to get him to eat.



I have to be very careful though, and not push it
too far back in his mouth as the vet warned me that, in his weakened
condition, his swallowing reflex will be slower and he could choke.
It does seem to help, as fairly soon after a force-feed, he will eat
of his own accord.

That's a very good sign! Often eating a little stimulates a cat's appetite.



Don`t laugh, but sometimes I feed him from a
teaspoon to save him the bother of sitting up or getting out of bed!


If I told you some of ways I've pampered a sick cat- you'd laugh!



He`s such a daft dollop that I think he forgets there is food
available nearby - or he can`t be bothered to go and get it.



Why should he? He knows you'll serve him in bed! He's not daft- he's
*smart*! LOL!




My thanks to everyone who has replied and for your advice and good
wishes.

Kate

Keep the faith!

Best wishes and good luck.

Phil

Any cat who is not getting enough food(for whatever reason) will lose
weight, become weak, tired, totter, lose its balance, not have enough
strength to walk any distance and this can progress further to signs of
anorexia and hepatic lipidosis where the cat doesn't even want to eat anymore.
When people develop anorexia it's because they don't eat and they show all
of the signs your cat does. if and when they start to eat again , the
signs of starvation start to diminish . What is interesting about your
comments is that your cat wants to eat- that's a big plus you can work
with. Also, for all of the weight loss your cat " got up very quickly"
and is " chirpy". Got up very quickly? Chirpy? Wants to eat? It sure
looks like these are all signs of a cat who is wanting to get well but
doesn't know how. Is it reasonable to put your cat down because you and your
vet don't know how either? Why hasn't your vet prescribed Cyproheptadine, a
safe and highly effective appetite stimulant? An acquaintance has a cat
with CRF. If, at the end of the day his cat has not consumed an adequate
amount of calories( as determined by the vet) it is supplemented by assisted-
feedings of pureed raw chicken( deboned, no skin or fat) with carrot
juice and other supplements added.
Here is what one person did:

Subject: Full recovery of a cat with chronic renal failure (CRF)
Date: Wed, 12 May 2004
From: Kristen Hanson

"My cat had chronic renal failure. I called Dr. Will Falconer , and our
cat is doing a million times better. He is like a kitten again and is so
full of energy and life! We haven't seen him look or feel this good since he
was a kitten. He is also working with our kitten who is having some issues
as well. He is wonderful to work with and listens to what is being said and
responds accordingly. What we may think are insignificant things he picks up
on and addresses them as to whether or not they are real concerns. I
recommend him to anyone. Thank you so much for the information. It has
saved Zeke's life. Here is what we did for Zeke:
We changed his diet and we also started giving him just a few drops of the
homeopathic remedy Sulphur at night and a Transfer Factor Plus in each meal.
He and our kitten did ok on the raw diet at first but then something went
horribly wrong and he couldn't stop vomiting after our attempt with veal.
Then after that the other foods we tried just didn't work. Dr. Falconer was
paged during the vomiting episode and he then prescribed 3 Nux Vomica diluted
in 8 oz. of water and give him 1/4 of a tsp. at night before bed. We have
been doing that instead of sulpher. We also went back to dry Innova for a
couple of weeks and are now working with Dr. Falconer and a person up here
who is helping us switch both of our cats (and dogs) slowly over to B.A.R.F.
so it is an easier switch to them. It's like having new animals! Zeke is
especially more spunky. He is walking along our banisters and takes naps
high up on top of our cupboards. He hasn't done that since he was a kitten.
He also is more willing to play with toys and loves his bird feather toy.
It's an amazing difference. His body is able to digest and process these
natural proteins. We are feeding him ground chicken wings and necks and I
mix in a touch of kiefer and egg yolk. We take the whites out of the eggs
since that is not good for his kidneys. Hopefully we'll be able to expand
his choices but that is all he will eat at the moment. He turns down duck,
beaver and beef. We will be trying lamb here shortly. But the key to our
cats is taking things extremely slowly. Even our kitten is not too keen on
the whole raw thing, but now Kiefer is her favorite and you can't keep her
away from the jar when we bring it out. "

I wish he was a more typical example of a
hyperT sufferer. Then he wouldn`t be starving himself to death. I
have occasionally force-fed him with a syringe to give his stomach
something to work on, as it will be sore if it is left empty for too
long and so discourage him from eating all the more (do cat`s suffer
from gastritis?). I have to be very careful though, and not push it
too far back in his mouth as the vet warned me that, in his weakened
condition, his swallowing reflex will be slower and he could choke.
It does seem to help, as fairly soon after a force-feed, he will eat
of his own accord. "

That the way it worked for the acquaintance who has a cat with CRF. The cat
wouldn't eat and he would assist-feed(force feed) numerous little small meals
numerous times a day. He said that it always surprised him that the cat
wouldn't eat on its own but after a few spoonfuls the appetite seemed to
kick in as though a switch was turned on but he kept having to turn that "
switch" on by feeding the cat with a syringe . As the cat regained strength
he found that he just had to give a few syringefuls and the cat tried to eat
on its own Then it got to the stage where he'd put the bowl of food down
and the cat would walk away from it. He'd take some and smear a little on
the cat's mouth, the cat licked it off and he was amazed that the cat
promptly started ravenously eating the food in the bowl, yet, hungry though
it was, it didn't eat until the actual taste of the food triggered the
appetite and the cat found it was ravenously hungry.lt seems to be working
the same way with your cat who is at the stage of starting to want to eat on
his own after you trigger his appetite by feeding him a spoonful or two. If
you have the patience to keep on, there is no reason why your cat can't
progress too to eating, eventually on his own so that you'd only have to
supplement with assisted feedings if, at the end of the day, your cat had
not consumed the required amount of nutrition.

"Phil P." wrote in message
...

I think (hope) you might have better luck with the gel since it
doesn't go
through the digestive track.

If Toby isn't cooperative, you might find it easier to apply the
methimazole
to your finger (w/cover) and then apply it to the inside of his
earflap
instead of applying it directly on his earflap. You must rub it in
for
about 30-45 secs. and wipe off the ear about 20 minutes later. Keep
your
other cats away from him so they don't lick his ear.

Toby is usually very good at taking his medication, especially if I
catch him in relaxed mode, and he loves having his ears rubbed anyway.

Yes- cats can have gastritis but the real danger is hepatic
lipidosis (fatty
liver syndrome) if he doesn't eat.

As well as all his other problems - or because of them - Toby`s liver
is already enlarged, unfortunately. Today he is still anorexic and I
have had to resort to the syringe feeding again. I can`t give him too
much at a time, as he gets very distressed, and with his high blood
pressure I am worried that I might trigger a stroke. Tomorrow I am
going to ask the vet to have a look in his mouth to see if he has
ulcers, or something else that might make his mouth sore and
discourage him from eating. He only has one tooth now, but that could
be causing pain. However, in his condition he couldn`t withstand an
anaesthetic to have it removed.

In fact, I wanted to see the vet today (Sunday) as I thought that Toby
might be in need of emergency treatment and I needed advice. However,
I did not realise that our vet practice, along with many other local
practices, uses an agency for out-of-hours emergency cover, who do not
have access to patient history notes. Also - and this gave me quite a
shock - this agency charges a whopping £90 sterling consultation fee -
excluding treatment, of course - which is more than four times the
usual fee. I realise that this huge sum would deter the frivolous,
but cannot help thinking that they are taking advantage of distressed
owners and their pets; if an animal is involved in a road accident,
for example, or is otherwise badly injured, then the owner would have
no choice but to pay or let their pet suffer. It doesn`t seem right
to me.


Kate