Presents with:
• Inability to eat enough on her own.
• Physical weakness, inability to climb without stumbling.
• Sometimes shaky after taking Mirtazapine-drug interaction? Low glucose/pot; hyper/hypo?
• Exhibits leg and facial twitching.
• Mirtazapine no longer has the anxious/eating affect; does not cause her to want to eat; not acting long term for three days.
• Mirtazapine didn’t work well with Benazepril or Gaba or Cerenia to help her eat. Was made weak on benazepril; improved after ceasing.
• Became weak on gabapentin. Improved after ceasing.
Contraindications that may cause issues for Katharine:
• Gabapentin is contraindicated to Mirtazapine. Made her weak, not eat?
• Gaba is contra to phenobarbital. Made her weak? (Side effect for humans-weak, disorientated, etc.)
• Mirt is an antidepressant. Made her weak?
• Mirt-processed in liver/renal. Can cause ALT elevations, hepatic injury. She has had increased levels this past year.
• Mirtazapine and Cerenia do not work well together for her. Cannot be given the same day.
• Antihistamines contra to phenobarbital.
• Steroids interact with phenobarbital.
- Chronic use of Mirtazapine drives up phenobarbital levels-we saw this in her blood count in December. We saw a decline when we ceased Mirtazapine in January after a month of not taking it.
History October-December 2023:
September
• Weight September at home-10.2 ½
• 9/13/23 cardio exam showed heart disease increased to 1.76. Put on Benezapril and Plavix.
• But that made her weak immediately. She stopped eating as much.
October
• Not eating became worse in October. Weight down 10/4/23 to 9.12 at vet.
• By 10/9/23 noticed that Mirtazapine is not making her eat as much, does not have the same effect.
• Feeding more AD by hand 10/16/23 at 6-9 ml twice a day.
• Cardio said to cut Benz to once a day 10/16/23.
• 10/19/23 Mirt began not working well at all. Effect lasted about two hours.
• She was appearing weaker, unable to stand straight and walk, and seemed tired and uncomfortable.
• 10/20/23 cardio said to give her Atenolol BID and stop Benz.
• Began feeding AD three times a day at 9 ml. each time.
• Tried Cerenia and Mirt together not working well. Better when we alternate days.
• She has trouble climbing and stumbles on stairs, and struggles with cat tree.
• Begins to exhibit shakiness and twitching in body and head. Front legs begin to slide around when she sits and stands.
• 10/22/23. Eating very little on her own at this point.
• Finally by 10/26/23 she responds well to Mirt and eats well on own. Hand feed evenings only.
• 10/27/23 weight is 9.12.
• 10/30-31 eats on own, hand feed 9ml AD evening only.
November
• By 11/3/23 Mirt is working as normal-she eats all day long, and appears to eat all week well enough. Continue hand feeding AD evening.
• 11/11/23 weight still 9.12. Continues through the month.
• She is stable enough physically but not strong.
December
• 12/3/23 wonder if lack of strength is reaction to arthritis and if should start gabapentin as previously discussed.
• Began gaba 12/3/23 at .1ml of 50mg/ml strength. She appears to walk stronger and to stand straighter with it after receiving it in the morning. She begins to spend each day playing with catnip toys and rolling around.
• But slowly over time, this decreases. By 12/13/23 she is appearing weak, tired, run down again. Not eating as much. Stops playing with toys, not as vocal or alert. Mirtazapine isn't working with gaba.
• Stopped gaba 12/15/23.
• 12/16/23 weight down to 9.9.
• 12/17/23 too weak to climb cat tree. Can’t climb shorter towers. Is very weak. Won’t eat. Not vocal. Shaky. Twitching more. Checked heart rate-150; BR seemed normal.
• 12/19 Added corn syrup to AD to combat weakness and twitching-thought low on glucose. Increased potassium a bit more (Renal K gel.) Adding glucose seemed to backfire (sign of pancreatitis?) She was even weaker and would not eat anything.
• Reviewed Dr. Miller’s October scan report and read about pancreatitis. Discovered it could be her liver and/or pancreatitis that is flaring up.
• 12/20/23 began ½ Cerenia each day.
• Asked for Hills ID from Cat Clinic and began hand feeding her that 9ml three times a day. Also fed her tunajuice 9ml three times a day. Tried to get her to eat tunafish.
• Added taurine pills.
• By 12/21/23 began to nibble on tunafish on her own. Continued hand feeding ID and tunajuice.
• *Noticed her face and eyes twitching as if she can’t close them and the lids are blinking rapidly. Her front legs twitch under her for a few minutes.
• 12/23/23-12/27/23 each day wakes up perky, walking fast down the hall, eating food overnight, very vocal, able to climb pet stairs, regular stairs, and cat condo. Then after her morning meds, quiets down; after hand feeding quiets more; after eating breakfast-which she is eating more of on her own, she quiets even more. Appears weaker and more tired by the evening. Continue to hand feed ID and tunafish juice and tuna that she eats on her own. She began eating dry food and dry treats during this week, also. Has more twitching in the evening. Breathing rate appears higher in the evening-CHF or heart or response to weakness and not eating or to being hand fed?
• Is receiving Forta Flora. Did not eat the Visibiome probiotic or Biome food.
Weight 12/22/23 at home 9.5
• Saw Dr. Miller 12/28 ultrasound gastro scan; pheno too high at 37; decreased pheno to ½ tab.
-Is mirtazapine driving up pheno level? Studies shows it can.
• Continued hand feeding ID four times a day, letting her eat what she would.
• Continued to be weak.
January
• 1/1 Still hand feeding ID; she’s not eating well enough on her own.
• Continues to do well in the a.m. when she wakes, and to decline in energy as the day progresses.
• 1/3-used ear drops and eye drops-ears full of black wax. Used ten days until 1/14.
• 1/4 began 75mg magnesium and 25mg potassium extra daily in a.m.
• 1/5 her weight at home is 9.3 ½.
• 1/5 began baytril. Perked her up a bit.
• 1/7 began cypro ¼ and she began to eat some on her own. Ate Fancy Feast and tuna.
• 1/8-1/10 She continues to be hand fed but begins to eat more on her own. More perky and alert also. Eats Fancy Feast and tuna.
• 1/10 weight at home is 9.5
• 1/11 Sees cardio, heart is fine, not related to issues of inappetence. She does not eat when she gets home. Declines to eat on her own. We increase feeding PO of ID.
• 1/11-14 We hand feed ID and offer tuna but not Fancy Feast.
• 1/15 She perks up and begins to eat some Fancy Feast on her own and we feed ID.
• 1/16 Not eating well on her own, only a few bites of dry food and tuna. We continue to hand feed.
- 1/17 sees vet for tests: PLI, cbc/chem, bile acids, pheno. Pheno level down to 14 now that she's off mirtazapine-need to increase pheno again. RBC low, liver values high, kidney values creeping up, etc.
- She seems to do well with Hills ID and tuna; then begins to eat more food on her own of Fancy Feast and dry gastro fiber food; then goes into a decline.
- Week of January 23 she was eating well on her own, stronger, playing with toys, able to climb and walk well. Seemed stable and that our schedule and process was working.
- Then she seizured Saturday January 27. Took her to the ER.
Possible causes of issues:
Her calcium is high. Hypercalcemia can cause tremors and twitching. Inappetence. Increased thirst and urination. Overall weakness. (Kidney stones, blockages.)
*These symptoms are also pancreatitis, heart disease, medications, high pheno, low pot, dehydration, lower calories/nutrition.
-Caused by CKD, cancer, other issues, taking too much calc, parathyroid-leads to too much PTH. Addison’s disease-hypoaldost and low glucorticoids produced-lethargy, not eating (how to test?), caused by dehydration. (Aldosteronism)
It’s a loss of calcium in the bones, goes to blood stream, excreted by kidneys, lands in organs through blood.
Test: Pth, PTHrp; aldosterone level, glucorticoids?
Steroids and furosemide help body not absorb calc. Helps kidneys excrete calc into urine.
*Test urine for calcium? Would be high if more is excreted into urine?
Fiber-gastro response food helps to fight calcium buildup, and renal CD diet.
Addisons: auto immune disorder, with low corticoids, with inappetence, weight loss, lethargy, dehydration; also shock, low blood pressure. Poses like IBD and CKD.
-does she have abnormally small adrenal glands?
-needs mineralcorticoids and steroids.
Cushings: hyperadrenocorticism, with increased thirst and urination, poses as CKD, muscle wasting, enlarged liver BUT increased appetite. Similar signs to diabetes.
Hyperaldosteronism: adrenal disorder. Caused by tumor in adrenal gland. Also idiopathic. Causes CKD. Or is misdiagnosed as CKD. With muscle weakness, lethargy, HIGH BLOOD PRESSURE (as with CKD, heart disease), loss of appetite.
-test with test to MSU.
High anioin gap-is metabolic acidosis. This test is an indicator of your pet’s acid:base balance, its blood pH and its bicarbonate buffer blood reserves. It is critical that the acidity (pH) of your dog or cat’s body be kept within a very tight range by the continual presence of carbonate (=bicarbonate=HCO3-) in its blood and your pet’s kidney’s ability to discharge excess chloride into its urine while conserving bicarbonate.
-caused by CKD, diabetes, When your pet’s blood sugar levels are not under control, the end result is metabolic acidosis – in this case lactic acidosis and ketoacidosis – as those products build up in your pet’s blood stream. A similar effect occurs in starvation, a cause of ketoacidosis as well. Also, lack of blood flow and oxygen to the body-heart disease, etc. Also-kidney, urine stones, blockages, A deficiency in aldosterone, as occurs in Addison’s disease can also cause a mild increased in your pet’s anion gap.
Ketoacidosis is a metabolic state caused by uncontrolled production of ketone bodies that cause a metabolic acidosis. While ketosis refers to any elevation of blood ketones, ketoacidosis is a specific pathologic condition that results in changes in blood pH and requires medical attention. The most common cause of ketoacidosis is diabetic ketoacidosis but can also be caused by alcohol, medications, toxins, and rarely, starvation.
High ALP- The main use of ALP is as a sensitive indicator of cholestasis in the dog (it will increase before bilirubin), however it is non-specific because corticosteroids (exogenous or endogenous “stress”) induces production of this enzyme, with subsequent increases in serum or plasma activity. In the cat however, ALP is a specific indicator of liver disease, whereas in large animals, the enzyme is less useful as it is insensitive, cholestatic disorders are infrequent, and reference intervals are quite broad.
The major isoforms that can be measured in animals are liver-ALP (L-ALP), corticosteroid-ALP (C-ALP; only in dogs), bone-ALP (B-ALP) and intestinal-ALP (I-ALP), but there are others including leukocyte-ALP and placental-ALP.
• Although alkaline phosphatase is considered a “liver enzyme,” it is produced by other cells, too.
• Alkaline phosphatase levels can be affected by many things, including certain medications and a variety of illnesses.
Certain medications, such as steroids, can cause this level to increase. Additionally, a variety of medical conditions can affect the ALKP level.
Most of the conditions that affect this enzyme cause the blood level to become elevated. The following are a few conditions that cause an elevated ALKP level:
• Pancreatitis (inflammation of the pancreas)
• Gall bladder disease
• Hepatitis (inflammation of the liver)
• Liver failure
• Cancer affecting the liver or bones
• Hyperadrenocorticism (Cushing’s disease)
• Diabetes
• Toxic injury to the liver
High albumin- Albumin is a major protein in a cat’s body that originates in the liver.
Diseases indicated by low levels of albumin are as follows:
• Chronic liver disease
• Inflammatory Bowel Disease
• Pancreatitis
• Pyothorax (an infection in a cat’s chest cavity)
Unlike low levels of albumin, high albumin in cats has been found to be much less of a cause for concern. This is because, while low levels of albumin indicate loss, high levels indicate overproduction.
The most common high albumin cause is dehydration in your cat or a diet that is abnormally high in protein. While both dehydration and improper nutrition are a cause for concern, both can be easily fixed, and neither indicates underlying disease on their own.
High calcium can drive down PTH-high calc tells body PTH isn’t needed unless there’s a disease of the parathyroid.
- High calc binds to phos, lowering phos.
-Magnesium acts as a phos binder if given more than body needs-good if need to drive down phos.
*She has low phos-anemia?
-low phos means low bicarb, danger to kidneys/indicates CKD
- high glucose levels might also be interfering with this phosphorous levels. Poorly controlled blood sugar levels or diabetes, might not allow the body to absorb phosphorous.
-low phos indicates diabetes and hepatic acidosis; can be due to not eating well, too much calc or magnesium.
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