Vet360 Vet360 Vol 05 Issue 03 - Page 17

FELINE MEDICINE about therapy when cats are in the early stages of CKD (International Renal Interest Society [IRIS] stages 1 and 2) will help pave the way to successful management. These early stages are a good time to talk about nutritional changes. For example, if the client is feeding Fancy Feast, which is high in phosphorus, then talk about switching to a high-quality senior diet. This is also a good time to plant the seeds about regular follow-up and explain that it’s important to track changes over time. These simple conversations will help guide your client and avoid overwhelming them, which erodes the human-animal bond. Early CKD is also a good time to talk about doing some additional diagnostics to determine if there’s identifiable disease that can be treated, such as imaging to look for kidney stones or urine cultures to look for chronic infection, says Dr. St. Denis. If there are money constraints, then you can plan to test over time to help soften the financial impact. Utilize the phrase “If not today, how about next month?” to direct your client’s actions. Therapeutic kidney diets—they get the job done The most important thing to ponder about nutrition in feline CKD is whether the cat is eating enough, Dr. St. Denis says. This is more important than what the cat is eating. Maintaining adequate caloric intake and muscle mass is critical to avoid protein malnutrition. But, as you already know, ensuring adequate intake in a cat can be very challenging. Working with the client and providing education in this area is an important therapeutic strategy. If the cat isn’t eating enough or is underweight, then Dr. St. Denis recommends feeding 1.2 to 1.4 times the resting energy requirement (RER). Most geriatric cats need at least 1.1 times RER. We all know that switching diets on a CKD cat that’s experiencing decreased appetite can be challenging (understatement of the century). Dr. St. Denis recommends changing the diet earlier rather than later. Cats with CKD should be eating a diet that contains restricted phosphorus and highly digestible protein that meets or exceeds minimum standards. A therapeutic kidney diet that meets protein needs and contains complete amino acid profiles, plus omega-3 fatty acids, which have renal protective properties, will help ensure that your clients’ cats will get everything they need. for nausea and inappetence. If the cat won’t eat or is severely malnourished, don’t hesitate to place a feeding tube to ensure caloric intake and medication administration. What about uraemic gastritis and ulcers? Historically, we prescribed antacids in CKD cats to prevent gastritis, but a new study has found that cats with CKD may not have elevated stomach acidity as compared with healthy cats. 1 Dr. St. Denis hypothesizes that the inappetence associated with uraemia is more likely due to chemoreceptors in the brain and less likely to be associated with elevated gastric acidity, making antacid treatment in cats with CKD less likely to help with nausea and inappetence. Avoid polypharmacy! Don’t reach for the antacid unless you are seeing melena or bloody vomitus. If nausea is under control, then appetite stimulants are helpful. In fact, the FDA recently approved a transdermal formulation of mirtazapine for cats. Mirtazapine can be used daily, but if you’re noticing serotonin syndrome with administration, (“hyperactive meowing,” as Dr. St. Denis calls it), then dial down the dose and use cyproheptadine as an antidote. Pain management When I graduated from vet school, we didn’t automatically associate pain with feline CKD, but now we know that these cats are hiding pain, due not only to CKD but also to occult degenerative joint disease (DJD), which is prevalent and underreported in senior cats and a serious obstacle to a good quality-of-life goal. Dr. St. Denis recommends talking to your clients about subtle signs of stress and pain from DJD and getting these cats on pain management sooner rather than later. Here are Dr. St. Denis’ favorite pain medications for cats: • • • Old, scrappy and not hungry If your CKD patient isn’t eating, determine if the inappetence or nausea is due to a contributing disease, dehydration or azotaemia and treat that first, before starting appetite stimulants. Maropitant is safe to use in cats with CKD, and it’s labeled for oral, subcutaneous and intravenous administration. Ondansetron is also effective for nausea, either orally or intravenously. Mirtazapine also works well • • • • Buprenorphine, as a sustained release formulation or given intravenously for hospitalised patients Gabapentin (Dr. St. Denis recommends starting with evening administration because of initial ataxia and sedation and says to be sure to advise clients of initial side effects) Nonsteroidal anti-inflammatory drugs (NSAIDs): robenacoxib (Onsior—Elanco) and meloxicam have good studies that show safe long-term administration, provided that the cat is hydrated and properly monitored and that the client understands the risks and benefits. Ketamine intravenous constant-rate infusion for hospitalised patients Polysulfated glycosaminoglycan (Adequan— Luitpold Animal Health) Duralactin (PRN Pharmacal) Prescription Diet k/d + Mobility (Hill’s). Issue 03 | JULY 2018 | 17