Lactulose and hypercalcemia?

[jennyjen]

Hi everyone,

From talking to Rang_27 and searching through the forums, I'm very curious to know if anyone has had a similar experience to what I'm about to explain. Both Rang_27 and I have had very similar experiences with a possible hypercalcemia-lactulose connection, and it looks like another TCS member may have as well. It looks like our kitties all had elevated calcium levels that seemed to correspond with starting or increasing the amount of lactulose given and/or saw a decrease in calcium after reducing or discontinuing lactulose. It also looks like all of our cats have gone through similar (if not almost identical) testing without ever finding the cause of the hypercalcemia, and all of our vets do not feel that there is a connection to the lactulose (not that I blame them, since there doesn't seem to be any clear documentation of a connection). I know that for a while, the similarities between Rang_27's situation and mine were so striking that I started to wonder if our cats were long lost relatives!

I'm wondering if this may be a more widespread issue that just hasn't been noticed, possibly because long-term use of lactulose isn't all that common? Has anyone else had a cat treated with lactulose who was also diagnosed with idiopathic hypercalcemia? Maybe it's just a coincidence, but I'm interested to know if it might be a common thing that gets overlooked.

Thanks everyone!

 

[pookie-poo]

Cleo has CRF, and also tend to run a high normal or high serum Calcium. I did have her PTH and iCa tested at MSU, and she was within normal limits. She was started on a dose of 24ng of Calcitriol, every other day. Her serum Calcium remains usually high normal now. She does not receive lactulose though, so perhaps my info is irrelevant to your query. Calcitriol is used to prevent soft tissue calcification that often happens in CRF, due to hyperparathyroidism.

 

[rang_27]

Anyone that has been following my story knows that Jordan's blood calcium began to drop down & got with in normal only after I had him completely off the lactulose. The vet told me in the past that it was unlikely that his elevated blood calcium would just go away, now he's saying if his blood calcium continues to reduce the way it has been he could betaken completely off his pred. JennyJen & I have had many of the same tests to determine why our cats had elevated blood calcium. Both of us were told it was probably cancer & I was specificly told lymphoma. Last August I was told Jordan might only live 1 month if I chose not to do anything for him.

JennyJen & I have just been left with a lot of questions about "Idopathic Hypercalcimia" and no answers so we are trying hard to find any answers.

 

[pookie-poo]

I do remember reading about Jordan's hypercalcemia last fall. Cleo was also given a tentative diagnosis of 'hypercalcemia of malignancy." I remember reading about several cats on the CRF site, who's hypercalcemia was managed by switching from Normosol sub-Q fluids, to normal Saline or Lactated Ringers. I don't remember reading about Lactulose being considered a trigger for hypercalcemia, and I find both of your stories being so similar, very interesting! It is something that I want to remember for my own peace of mind, and for reference, in case Cleo ever needs to go on it. Especially since CRF cats often develop constiation as a symptom of the disease. Have either of you posted this question on any of the CRF support sites? You might find more people who have experience with the use of Lactulose, and be able to find out if it is something that has been documented or noticed by those members. Good luck!

 

[blaise]

Originally Posted by Pookie-poo

...I don't remember reading about Lactulose being considered a trigger for hypercalcemia,,,

My own "personal best CRF guide" clearly indicates that this connection is not at all uncommon. Rang_27, I think I may have previously given you this link from the CRF reference site. While Helen, the owner of that CRF site, does not provide any reference to studies/reports, she may very well have some - or, be able to direct you toward some. She can be contacted directly through her site and, if you want to persue this further, I'd suggest that either of you get in touch with her.

Meantime, a very effective alternate to Lactulose is Miralax, as indicated at this link to Helen's site.

Someone else who, I believe, has experienced the same causative rise in calcium levels is luvmycat1 with Poopsie.

And, as for both of your Vets' ignorance of the connection....frankly, I'm not surprised. From my observations, few Vets are equipped with the experience and in-depth knowledge required to manage chronic health conditions and to know all the intricacies. And, frankly, even some of the "specialists" could use to learn a few things. NOW, none of what I'm saying is intended to criticise/diminish these Vets. It's just a commentary on the way things are.

One further comment...there are online support groups for most feline chronic health conditions. The collective knowledge and experience in those groups far outstrips the individual knowledge and experience of most of the group members' individual Vets.

 

[jennyjen]

BLAISE, that's all very good information. I've visited that site a lot and saw that she mentions the possible connection. I'm going to do some research on Miralax too. Treating Bailey with lactulose was supposed to be temporary, but after trying to discontinue treatment a couple times, she ended up at the vet in need of de-obstipation. Poor girl. It's so weird too, because after all the diagnostics they did, they determined that she doesn't have megacolon and couldn't determine why she has a tendency to get constipated (I think it's the same with Rang_27, please correct me if I'm wrong). She's gone through several dietary changes too in an attempt to control it, but the outcome is always similar.

I know what you're saying about the vets too. I think veterinary medicine has come a long way, but there's obviously still a long way to go. I don't fault anyone for being skeptical of a connection. As with human medicine, it's a constant learning environment. New discoveries are being made all the time regarding conditions, their causes, and previously undetected side effects of treatment. And of course, there will always be those who experience them before they're widely accepted in the medical community. I hope that made SOME sense. It's early and I'm not a morning person.

 

[blaise]

Originally Posted by JennyJen

...Treating Bailey with lactulose was supposed to be temporary, but after trying to discontinue treatment a couple times, she ended up at the vet in need of de-obstipation....(they) couldn't determine why she has a tendency to get constipated...She's gone through several dietary changes too in an attempt to control it, but the outcome is always similar...

At the risk of starting an avalanche of dietary diatribe....could you give a short history of what she's been eating to the present - or, if already posted, give me a link to it? And, how old is she? Better yet, if there's a thread with her medical hx, maybe a link to it. (Maybe I shouldn't be so lazy, and just go looking through your previous posts

)

 

[jennyjen]

Originally Posted by BLAISE

At the risk of starting an avalanche of dietary diatribe....could you give a short history of what she's been eating to the present - or, if already posted, give me a link to it? And, how old is she? Better yet, if there's a thread with her medical hx, maybe a link to it. (Maybe I shouldn't be so lazy, and just go looking through your previous posts

)

Haha, I don't even know if I can remember all the different things I've tried. Before I say anything, I want to tell you that I don't give her the food I give her because I'm under the impression that it's of great quality. I know that there are many "better" options, but they're only better if she'll eat them. Without getting too detailed about the arduous year she and I had in 2007, I settled on the food she gets now because it was the only thing I could get her to eat. While I wasn't too happy about having to settle for food of questionable quality, it came down to giving her whatever cat food she would eat, or giving her high-quality food that she would not eat. For obvious reasons, I chose the first option.

Anyway, she gets a combo of wet/dry, and I have tried cutting out dry food altogether, but she will not eat enough wet food alone to sustain herself. I tried pretty much every premium brand that was out in 2007, including some low-allergy foods in case she had food allergies. Sometimes she would eat certain foods for a period of time, and then stop. Some foods she wouldn't touch, and others she would eat and then puke up (and I did phase them in properly). After she decided that she didn't want to eat ANYTHING (which marked the discovery of her hypercalcemia), I started giving her Hills I/D dry and wet. Trust me, it's not anywhere close to my first choice, but we were at a point where I was lucky if I could get her to eat anything, and she would eat that. She's still on I/D dry, but she eventually stopped eating the I/D wet. For the past year, she's been getting I/D dry and Meow Mix Market Selects for wet food (again not my first choice, but she certainly made it very clear that SHE decides what she will or will not eat). Right now I'm trying to get rid of the Meow Mix because they keep raising the prices and I'm getting increasingly irritated by the amount of bones I have to pick out of it. I'm introducing Weruva now, hoping that the high water content might help soften her poo.

Now for a little background, she's 13 now and started having digestive issues when she was about 10 1/2. I adopted her when she had just turned 8, and she had spent all of those years with one family on a diet of dry food only. I changed her food when I first adopted her, eventually landing on Nutro Natural Choice Senior dry food as the winner. She was eating that food for about 2 years before she had her first bout of constipation. I have no idea what sparked it. I started giving her wet food after that to help her get more moisture in her diet, and I also started giving her lactulose at that point. Her dosage has varied, but since the introduction of the I/D dry, I've been giving her about 2-3ml per day. Previously, she would get anywhere from 4-6ml per day, which is also when her calcium levels went up. Also, she weighs around 11.2lb.

Anyway, that's what I can dig out of my memory.

 

[sarah1]

I have a kitty that will be 5 years old on Friday April 13th.  I recently lost my husband of 48 years and all the health problems with my Standard Poodle and 4 cats got worse when they lost their daddy, plus lots of new ailments.  Our little Sarah developed hypercalcemia and was in the hospital 4 times.  She went through many exotic tests and they all came back within normal limits.  The diagnosis was idiopathic hypercalcemia.  It ended with Sarah being on a feeding tube for months and being fed Clinicare.  Naturally, her calcium started coming down.  She was on Fosamax and an IV drip of the same type of drug.  Nothing was able to hold her calcium levels down.  On Easter Sunday evening I received an email from our Internist saying that she thought she cracked the case at last.  Lactulose.  Sarah has been taking it most of her life.  She is now off the Lactulose and on Miralax.  She is eating and looking more like her old self.  Next week we will recheck her calcium and see if it has come down. I am so grateful to have a doctor that didn't give up on Sarah and kept researching until she came up with an answer. Now Sarah will be celebrating her fifth birthday and has the promise of a bright future.

 

[heather doherty]

I hope Sarah is still doing well.  Out of curiosity, what was her Calcium level?  Sounds like it must have been quite high.  The reason I ask is that my kitty, Hazel's, level is 15, and they are saying it's too high to be idiopathic.  However, they can find no other cause.   Thanks!

 

[miranster]

I have a cat who was diagnosed with Hypercalcemia. There are 2 theories that my vet  believes is causing this epidemic in cats… They have been diagnosing cats left and right… anyway One major issue is Carbohydrates. The other he believes could be the all the vitamins they are putting in pet foods. Some cat foods have large amounts of vitamin D which is elevating levels in the blood. On my cat I have began slightly cooking for her and keeping her away from commercial pet food. It was obvious in her Carbohydrates was a major offender. She would get swollen limbs at various intervals and that has stopped since keeping her off sugar. Lactulose has sugar in it… which could be why its affecting your cats calcium levels. I actually brought this up to my vet because cats with hypercalemia tend to get constipated. (mine had to undergo 3 enemas!) He said lactulose isn't anything that gets digested so it shouldn't enter the blood stream, but he also said he isn't 100% sure. this is just scientific theorizing. Anyway… if you are giving it due to hairballs or constipation you can use cat grass (leave some our for them or finely chop up a teaspoon of it and mix in their food) OR add a pinch of psyllium husk to their food twice daily. Most cats respond well to Miralx as well (no more than 1/8 teaspoon daily… but less usually does the trick) - Hope this helps

 

[heather doherty]

Thank you, that is great information. Hazel is doing well on the Miralax. Her vet says 1/4 to 1/2 half teaspoon in each of her 2 meals is ok. She takes 1/4.

 

[jennyjen]

As the original poster, I'd like to share some additional information. I know this is an old thread, but I never followed up on what eventually happened with Bailey. After a litany of tests, they could not find the cause of her hypercalcemia and deemed it idiopathic. She went on prednisone and was on it for probably a year (I can't remember exactly). The prednisone kept her calcium levels within the normal range (total and ionized). She was still on lactulose the whole time.

Toward the end of 2010, she was diagnosed with a bilateral perineal hernia. Her poop was soft and was moving through her colon, but she couldn't push it because her perineal muscles were so atrophied. The result was that the poo would collect right behind her rectum and sort of ballon out to the sides (if that makes sense).

Anyway, Bailey went through surgery to repair the hernia (it had to be done by a veterinary surgeon). She ended up getting an infection, and then we all realized that we probably should have taken her off of the prednisone prior to the surgery, as prednisone suppresses the immune system. We took her off of it while the infection cleared and she recovered, with the intention of putting her back on it after.

After surgery, Bailey no longer needed lactulose. She could poop like a champ. I'm not sure exactly when I had her total and ionized calcium retested (maybe a month or two after the surgery), and both of them were well within the normal range. I tested it every few months for the next year, and the results were normal every time. Pretty interesting!

Whether it was the lactulose or some other biological process that was affected by the surgery, I can't say for sure. I think there's a pretty good chance that it her hypercalcemia could have been caused by lactulose, particularly as she was on considerably high doses. For the past year, we've noticed a recurrence of the perineal hernia, though not as severe as it was when surgery was performed. With her age (19) and stage 4 CKD, I won't put her through such an invasive surgery again. I use miralax now to counter the potential of constipation from her phosphorus binder, and it has worked well for her. She also gets cisapride to increase motility (still no megacolon, but there's something else going on that causes food to move through her very slowly).

Just wanted to share that with anyone who might be looking for information about the possible connection with lactulose and hypercalcemia.

Jen :-)

 

[my cuddles]

I finally found information on this connection. My Cuddles and Stacey girls both have constipation issues. Cuddles lived with major problems most of her life. She was put on lactulose. Was acting a little strange but not dangerously. I came home to find her gone. She died in her sleep. I think the stress on Stacey having lost her mom and best friend. She suddenly got backed up. She had never had to go to the vet for any issues. They put her on lactulose. She started acting lethargic and confused. I didn't do a calcium check but she had all the symptoms of hypocalcaemia and so did my Cuddles now that I think of it. I called the vet, but he said that lactulose isn't absorbed and can't cause lethargy. I took her off and in 10 hours she started acting normal again. I believe lactulose killed my Cuddles. I hope they do some more research on this and possibly pull this medicine. I am now debating what the safest way of preventing and treating her constipation should be. I am not trusting veterinarians at this point. I hope everyone is aware of this potential hazard and keeps a close eye on thier animal if using lactulose. Can this be reported to the FDA?

 

[LotsOfFur]

I have one cat that I've had to take to the vet b/c of constipation. I know he received lactulose while there and ended up having an enema. I give him Miralax. Thankful to have found TCS and this thread.

 

[micknsnicks2mom]

hi and welcome to TCS to @my cuddles! i'm so sorry for your loss.

as @LotsofFur mentioned, miralax is a good alternative. my snick has had idiopathic hypercalcemia, the 'idiopathic' part means for unknown reasons (though much blood work was done, in my snick's case). snick had developed IBD years before the hypercalcemia, and had been on miralax for (also years) prior to the hypercalcemia. we never used lactulose. i prefer the miralax because it's bought over-the-counter (no prescription needed), it's easy to adjust the dose to what the individual cat needs each day, it's tasteless and can be added to wet/canned cat food (and my picky eater doesn't even taste the miralax in her food), and it's effective. i did get my vet's 'okay' to give my snick the miralax before starting her on it.

as for reporting lactulose to the FDA. you might contact the FDA to voice your concerns about this medication.

 

[my cuddles]

Thank you all for your advice. I've been focusing on this issue. It took a while, but have had some progress. I have Stacey on miralax. She did have to be cleaned out. Dr. put her on a high fiber diet and subQ fluids also. Everything goes well as long as she has fluids. She doesn't drink enough water and will only eat dry food. She is very picky. Doesn't even like people food of any kind. She is not patient at being messed with unlike my Cuddles who was so laid back. She won't let me give her fluids. I have researched all tricks for this and I'm losing the battle with scratches and bites. I am about 3 min. from vet and take her for but cost is adding up and have to work during Dr. hours. My determination to save my cat and having setbacks are giving me extreme anxiety. Any advice? Help!

 

[heather doherty]

Hi My Cuddles,

Everything you're doing plus Cisapride, acupuncture, and Chinese herbs (specifically MaZiRen) made the difference for my Hazel regarding constipation.

 

[heather doherty]

Does anyone find it interesting that all these kitties had both hyperCa and GI issues?  Hazel hasn't been on lactulose in two years but we continue to fight her elevated Ca with a biphosphonate, a diuretic, a steroid, and fluids.  I'm so sick of this "no known cause" hypercalcemia that is going to steal my baby.  I wish someone would find the cause.  I wish I could find the cause!

 

[tiggermarie]

My cat was diagnosed with Idiopathic Hypercalcemia 5 years ago. I switched her from Lactulose to Miralax, and the problem never returned. However, I also started aggressively treating her IBD at the same time, so I am not sure if the uncontrolled IBD or the Lactulose caused the Hypercalcemia.