Liver Disease, Cholestasis Cat

[Chaz Galloway]

The hardest part of all of this is seeing how lethargic he is. He hardly opens his eyes and sleeps all day. He was starting to show signs of lethargy before the biopsy and feeding tube, but I feel this has accelerated the disease process. Were still waiting for the results of the biopsy to come back, I just hope they come back and recommend a helpful treatment option before he suffers much more. I'm not ready to say goodbye, but if he's suffering then I know its not about what I want. Has anyone else had experience with liver disease and extreme lethargy? Should I be preparing myself for the worst?

 

[fionasmom]

Liver disease, and the biopsy which was just done, can manifest as inappetence and lethargy. It seems that you are seeing an up and down pattern which, as long as there are sufficient upsides and food intake, might be a pattern. You were given sufficient instructions as to the feeding tube? Don't feel that you can't talk to the vet; you have had major procedure and if you need support, you have already paid for it. Chaz may be very tired from the procedure, not necessarily in discomfort. Don't give up.

 

[Chaz Galloway]

Liver disease, and the biopsy which was just done, can manifest as inappetence and lethargy. It seems that you are seeing an up and down pattern which, as long as there are sufficient upsides and food intake, might be a pattern. You were given sufficient instructions as to the feeding tube? Don't feel that you can't talk to the vet; you have had major procedure and if you need support, you have already paid for it. Chaz may be very tired from the procedure, not necessarily in discomfort. Don't give up.

Did you go through a liver biopsy with one of your babies? Could you tell me a little bit about your experience?

 

[fionasmom]

My cats have avoided liver disease, for some reason for which I am sure that I can take no credit, but I have had several dogs with liver issues. One had a laparoscopic biopsy and it ended up being much more like major surgery. Nothing went wrong with the procedure, but the dog reacted much more to it with the same lethargy and lack of appetite that Chaz has. We did not do a feeding tube, but it was still a long process. It made me laugh because I was told that for most dogs who are in good condition the recovery was not an issue, but it begs the question that a healthy dog, or a young dog, probably does not need the biopsy in the first place.

 

[Chaz Galloway]

My cats have avoided liver disease, for some reason for which I am sure that I can take no credit, but I have had several dogs with liver issues. One had a laparoscopic biopsy and it ended up being much more like major surgery. Nothing went wrong with the procedure, but the dog reacted much more to it with the same lethargy and lack of appetite that Chaz has. We did not do a feeding tube, but it was still a long process. It made me laugh because I was told that for most dogs who are in good condition the recovery was not an issue, but it begs the question that a healthy dog, or a young dog, probably does not need the biopsy in the first place.

Thank you, it is reassuring to hear that someone else had a similar experience. Chaz was already losing weight and now he is just so skinny. The feeding tube is difficult because if you don't mix the food with enough water, the syringe feels resistance and wont push the thick food through the small tube. But if you use too much water, then the cat isn't getting very many calories. I really felt unprepared for the amount of work/time that comes with tending to a feeding tube. I'm not sure how one could manage a full time job away from home while caring for a sick animal that requires tube feeding. Luckily, I can work from home, but I feel veterinarians should really discuss all of this with caretakers without sugar coating.

 

[LelaCat]

I recently started using the Just Answer App/website for immediate vet advice. It does require a monthly fee($29, I think), but I have found it very helpful to have immediate advice. My vet specialist's office takes at least 24 hours but more like 48 or 72 hours to answer my emailed/telephoned questions. Granted, the app vets do not know your pet personally but have likely had other patients with similar conditions. I hope this helps.

 

[Chaz Galloway]

Chaz update!

We finally got his liver biopsy report back after ten days and they confirmed he has the chronic form of lymphocytic cholangiohepatitis. They suggested we start him on a pretty high dose of prednisolone (200 mg/mL at 0.5 mL) to shut his immune system down since its creating a constant loop of inflammation. If that doesn't help bring the liver enzymes down and get him feeling better, then the next step would be chlorambucil. All of the bacterial cultures came back negative and the copper analysis came back within normal range so he doesn't need anymore antibiotics. He does have some moderate liver fibrosis since this has been going on for a few months now. He's still pretty lethargic- that hasn't changed since the surgery. For the most part, he sleeps under the bed all day and night. I'm tube feeding him nearly all of his calories at this point. I'm working at night and feeding him every three hours during the day- so not much sleep happening. Its really exhausting. Has anyone had experience with the chlorambucil?

 

[fionasmom]

A number of us have used chlorambucil, including myself. It is tolerated very well by cats for the most part. Don't equate human chemo and its effects which are often unpleasant with small animal chemo as most are able to do fine with it. My Chelsea, who had SCL, was on it and I believe it definitely prolonged her life.

Any medication can have side effects, so being aware of those is important. For Chelsea, it was mostly lethargy, but as a semi feral, she started treatment late.

Leukeran/chlorambucil – IBDKitties
Chlorambucil for dogs and cats: Uses, Dosage & Side Effects.
Wedgewood can supply a different formulations if pills won't work
Chlorambucil | VCA Animal Hospital

 

[LelaCat]

My cat is has been taking Chlorambucil for almost 2 weeks now. She takes a compounded Marshmallow flavored liquid 0.1mg(10mg/mL) Chlorambucil every 72 hours. It was about $85 from Stokes Pharmacy. She had been having nausea and some vomiting prior to starting the Chlorambucil. The vet prescribed two liquid nausea medicines also, Cerenia and Metoclopramide, that she suggested we give 30-45 minutes prior to the Chlorambucil dose. She has done ok so far. She has been lethargic and hasnt wanted to eat much but is eating. Sometimes on the Chlorambucil dose days, she won't eat all day until the evening. She has a follow up vet appointment next Wednesday to check her liver labs. Hopefully it is working and her enzymes will be lower than last time.

Per the medication handling instructions:
I have to wear disposable gloves when drawing up the Chlorambucil and when administering it. I also have to wear them when cleaning her litter box. I double bag the scooped litter and throw it in regular trash. I also wear the gloves when giving her the nausea medicines because she drools a bit and the slip said Chlorambucil is in saliva as well.

 

[Chaz Galloway]

My cat is has been taking Chlorambucil for almost 2 weeks now. She takes a compounded Marshmallow flavored liquid 0.1mg(10mg/mL) Chlorambucil every 72 hours. It was about $85 from Stokes Pharmacy. She had been having nausea and some vomiting prior to starting the Chlorambucil. The vet prescribed two liquid nausea medicines also, Cerenia and Metoclopramide, that she suggested we give 30-45 minutes prior to the Chlorambucil dose. She has done ok so far. She has been lethargic and hasnt wanted to eat much but is eating. Sometimes on the Chlorambucil dose days, she won't eat all day until the evening. She has a follow up vet appointment next Wednesday to check her liver labs. Hopefully it is working and her enzymes will be lower than last time.

Per the medication handling instructions:
I have to wear disposable gloves when drawing up the Chlorambucil and when administering it. I also have to wear them when cleaning her litter box. I double bag the scooped litter and throw it in regular trash. I also wear the gloves when giving her the nausea medicines because she drools a bit and the slip said Chlorambucil is in saliva as well.

Do you have other cats? I'm worried I'll need to separate my two cats due to the chlorambucil.

 

[LelaCat]

Do you have other cats? I'm worried I'll need to separate my two cats due to the chlorambucil.

I don't. Just the 1 cat. I would double check with the vet, but I read that you don't have to use separate water bowls. Not sure about the litter box though.

 

[Chaz Galloway]

My cat is has been taking Chlorambucil for almost 2 weeks now. She takes a compounded Marshmallow flavored liquid 0.1mg(10mg/mL) Chlorambucil every 72 hours. It was about $85 from Stokes Pharmacy. She had been having nausea and some vomiting prior to starting the Chlorambucil. The vet prescribed two liquid nausea medicines also, Cerenia and Metoclopramide, that she suggested we give 30-45 minutes prior to the Chlorambucil dose. She has done ok so far. She has been lethargic and hasnt wanted to eat much but is eating. Sometimes on the Chlorambucil dose days, she won't eat all day until the evening. She has a follow up vet appointment next Wednesday to check her liver labs. Hopefully it is working and her enzymes will be lower than last time.

Per the medication handling instructions:
I have to wear disposable gloves when drawing up the Chlorambucil and when administering it. I also have to wear them when cleaning her litter box. I double bag the scooped litter and throw it in regular trash. I also wear the gloves when giving her the nausea medicines because she drools a bit and the slip said Chlorambucil is in saliva as well.

I'm wondering how your follow up visit went and how your cat is doing?

 

[LelaCat]

Thank you for checking!

The two weeks of Chlorambucil were hard on her. She lost weight even though she didn't have any more to lose. She was very lethargic and not wanting to eat. The labs just came back yesterday evening. Her AST liver enzymes came down from 2200 to 944. The vet attributes this to the Chlorambucil. She suggested we do 2 doses per week instead of every 3 days. She has been doing better gradually after stopping the Chlorambucil so we aren't sure if we want to do that again just yet.

The vet prescribed Mirataz transdermal cream(appetite stimulant) that we apply to her ear once a day. This has greatly helped with her appetite. She is eating a lot more and seems to have more energy.

Her b12 level was good, so we are continuing to give the oral b12.

Her Folate was low which can indicate a gut bacterial imbalance. The vet suggested we add FortiFlora probiotic to her food once a day.

Her Creatinine was high, like over 5 high.
The vet said she recommends a hospital stay with iv fluids or hydration at home or local vet every other day with a recheck in 3-4 weeks. She doesn't seem to be dehydrated...still drinking and urinating normally. The vet said this could just be from having 17yo kidneys/ chronic kidney disease. I also read that anorexia and anemia can cause this elevation and she has both. Lela seems to be doing worlds better than 2 weeks ago and we worry she will be miserable with multiple visits and the hump of fluids they give under the skin.

Her thyroid labs were normal, so no underlying thyroid issue.

We are taking some time to decide what to do as far as the Chlorambucil and the hydration. We just want her to feel good and be comfortable. She seems to be both right now. We don't know what to do just yet.

 

[Chaz Galloway]

I'm really glad to hear her values coming down, great work Lela & her pet parent(s)!!!

This is exactly what I am afraid of with the chlorambucil. My baby is to start his chlorambucil tomorrow, every other day for two weeks on top of the prednisolone, sigh. At our vet checkup last week, his liver levels were still on the rise despite the high dose of prednisolone hes been on. Good news is he has gained almost a pound since the feeding tube!! hooray!! I'm actually happy he still has the feeding tube in place, even though I was extremely overwhelmed with it at first. But I did specifically ask my vet about the side effects of the chlorambucil because we have already been through so much with the liver biopsy, feeding tube, and medications. She certainly downplayed the side effects saying he may or may not get some nausea, but that would be all to expect. Unfortunately, the downplaying of symptoms and lack of communication has been a constant issue with our vet experience.

I completely understand your reluctance on wanting to do more meds that make them sick and the never ending vet visits are stressful- for cats and parents. My husband and I are exhausted.This whole journey has been so time consuming, personally I haven't been able to leave my house or have any kind of life outside of caring for my cat for the last two months. You know your cat and you know whats best for her. Continue to keep me updated on her! I'll be thinking about you all.

 

[LelaCat]

How is Chaz doing with the Chlorambucil?

Lela is still eating well but is urinating more than before. We decided to do fluids at our local vet. We will drop her off on Monday for IV fluids and they will call us when she is ready to go home. Hoping this helps her kidneys a bit.

We are still thinking about the Chlorambucil since it was so hard on her. We don't want to take backward steps again. She seems to be gaining some weight and her coat seems more healthy.

 

[Chaz Galloway]

He's okay so far, but he's only had two doses. He did seem very lethargic on the first day we gave it to him, not wanting to eat as much as usual. I have also noticed that hes peeing way more than he usually does, and I believe this is his body's way of getting the medication out as quick as possible. Did you happen to notice more side effects the longer she was on the medication or was it the same right from the start?

Fluids are always a good idea! The two days of IV fluids they gave Chaz before the liver biopsy really helped flush the bilirubin, and I would imagine they would also help flush out any remaining medications so her kidneys aren't working over time. Is she also on prednisolone, if so maybe a higher dose instead? I wonder if there are alternative medications to try that wont be so hard on her? If the chlorambucil doesn't work then I will probably just insist on staying with the prednisolone vs taking a more aggressive drug again.

 

[LelaCat]

He's okay so far, but he's only had two doses. He did seem very lethargic on the first day we gave it to him, not wanting to eat as much as usual. I have also noticed that hes peeing way more than he usually does, and I believe this is his body's way of getting the medication out as quick as possible. Did you happen to notice more side effects the longer she was on the medication or was it the same right from the start?

Fluids are always a good idea! The two days of IV fluids they gave Chaz before the liver biopsy really helped flush the bilirubin, and I would imagine they would also help flush out any remaining medications so her kidneys aren't working over time. Is she also on prednisolone, if so maybe a higher dose instead? I wonder if there are alternative medications to try that wont be so hard on her? If the chlorambucil doesn't work then I will probably just insist on staying with the prednisolone vs taking a more aggressive drug again.

Sweet kitty. Keeping you and Chaz in my thoughts.

Yes, the side effects were worse the 2nd week she was on the Chlorambucil. It seems like it compounded the longer she was on it. It is mostly excreted through urine and feces, so your hunch seems likely. I wonder if Lela's kidneys issues are partly related to after-effects of the Chlorambucil also.

She is on 0.2mg prednisolone 10mg/mL. The vet thought she should remain at this dose. I don't know if that's considered a high or normal dose. She is only weighing 5 to 6 lbs. We are hopeful the fluids will support her kidneys and bring the creatinine down.

 

[Chaz Galloway]

I would consider that a normal dose. Chaz is on a pretty hefty dose of pred 0.5 mL at 20mg/mL- he also weighs 14 pounds though! Considering the kidney issues and difference in size, that sounds about right. The fact that you care so much to look into her care and research is far more than most people, I'm confident you'll make the best choices for her.

 

[LelaCat]

How is Chaz doing with the Chlorambucil?

Lela had IV fluids at the local vet on Monday and Tuesday this week. When she came home on Monday, she drank a lot of water. She hadn't eaten much while at the vet, but she ate pretty good overnight. Tuesday when she came home, she was wobbly/drunk seeming. I called the vet to ask if she had sedation, but they said no, just fluids and that she seemed alert when checked on throughout the day. They said she probably didn't sleep much bc of the noise and anxiety but if she worsened to take her to the ER. She took a few hard naps and seemed a little better after. She ate a little overnight. Yesterday, mu husband said she seemed a little drowsy or out of it and whined throughout the day. When I got home, she seemed pretty ok...laying on me and taking naps. She did seem a little weak but I assumed this may happen bc of the stress and fluid changes. The vet called last night and said her kidney labs hadn't changed much. Creatinine 5.0 down from 5.2 on Feb 8th. Still anemic, but I'm not clear on if she is more anemic than before or about the same. Her sodium and potassium were a little off. Im wondering if this is why she is exhibiting these symptoms. The local vet plans to call the specialist vet today and they give me a call this evening again. Today, Lela is still a little weak seeming and sometimes when sitting she has a little wobble like she can't just be still while sitting. She whines and goes to the litter box and is pacing around a bit. She finally ate some food and relaxed on the blanket to take a nap.

I read online that cats can seem a little off after getting IV fluids and it can take a few days for them to normalize. We are feeling awful that we agreed to the fluids for the second day as she seemed fine before the fluids despite the high Creatinine. She was in a good rhythm of eating and was feeling somewhat comfortable. Wondering if you or anyone else has any experience with cats and IV fluids?

 

[Chaz Galloway]

My other cat Hunter seemed drunk and almost fell down our stairs after he had fluids for the first time. It didn't last very long, maybe 4 hours and then he started to look like his normal self but it was scary at first. Chaz did not react that way to IV fluids though, he seemed to feel a lot better after he got them.

When you say she is pacing, is she going around in circles? I ask because my vet warned me about pacing and head pressing when the liver levels get to be too much for the body to handle that it starts to affect their brain and mental clarity. But you would think fluids would help that concern. Were the sodium and potassium levels low or high?