Suspected IBD in 15 year old Hyperthyroid cat - I have some questions

[Mac and Cats]

Hi, I apologize in advance as this is probably a very long post.

First some history before I get into my question: We have lost 3 cats in an 18 month span during the pandemic (lymphoma, CKD and then another confirmed gastro disease (I can't remember the name) that has only been recently recognized since 2017 (I think)). So, I was very concerned this past weekend when our 15 year old hyperthyroid cat was not wanting to eat very much. He only had partial loose stools a couple times over the weekend and he threw up bile once. We have had him for 2 years and adopted him knowing he had hyperthyroidism. He takes Methimazole twice a day. When we first got him, he would eat anything and everything we gave him because he had untreated hyperthyroid and was starving. The day we got him was the day we started him on hyperthyroid meds. He went from 7.5 pounds to 10+. I had been working hard to try to find something he would eat that had lower phosphorous levels in it as the vet had said he had beginning stages of CKD (he refused to eat any of the prescriptions). He has a history of liking something the first few times I give it to him and then once I buy a case, he loses interest. Recently, I discovered (or so I thought) that he just wanted a variety of foods. He has also lost a bit of weight recently and we had to adjust his medication and go up to 5mg in the evening dose. We finally got him eating more and he was on a rotation of grilled fancy feast, Tiny Tasters, some Weurva, Tiki Cat and Merrick. The only food I have been able to get him to consistently eat over the past 2 years is Purina Pro Plan Focus Urinary Chicken Entree (a food we use to feed one of our cats that passed recently). About a month ago he stopped wanting anything to do with it. I didn't think too much of it at first because he is a very picky boy. I've tried TONS of different foods with him over the last 2 years and had minimal success with what he was willing to eat.

This last weekend I took him to urgent care as he was not wanting to eat very much at all and turning his nose up at foods that he previously would eat. When I got really concerned was when he wouldn't touch the Fancy Feast because that is previously all he really wanted to eat. They did lab work and all his numbers came out normal. Even his kidney numbers, which have gradually gone down over the last two years. I've been through this type of thing with our two other cats that we lost in 2020 (lymphoma) and then in 2022 (the GI disease that I can't remember the name of). Obviously, I did not want a repeat of the outcome we had with our two other little loves. Urgent care gave him a small amount of fluids (he also has a heart murmur), a B12 injection and sent us home with Cerenia and Mirtazapine (both of which I had already been using for a day or two before I took him to urgent care). They recommended an ultrasound and I got him in on Tuesday. They said that their findings were consistent with IBD and said that we couldn't rule out small cell lymphoma without a biopsy. They also said he has mild chronic pancreatitis. They said that if we brought him back within a month we wouldn't need to re-do the ultrasound in order to do the biopsy. I am holding off on the biopsy for now. Before the ultrasound, but after urgent care, I had some success in getting him to eat the Sheba and Fancy Feast single serve portions. He always has a rough day or two after any vet visit and the ultrasound was very stressful for him because in addition to the stress of a strange vet place, he had a long car ride to and from. After the ultrasound visit, he wanted nothing to do with any of the single serve foods or any of his regular foods. I was able to get him to eat a jar of chicken baby food and some tuna fish and a few bites here and there of random foods. I was able to talk to our secondary vet (we talk to our primary later this evening) and we discussed how in the long term, I may be able to get him to eat a food that is better for his GI system, but that in the short term, he needed some help to eat as the Cerenia and Mirtazapine were not really doing it. Martazipine has never really worked well for him. He will get hungry on it, but then won't want anything I put in front of him even if I supply him with 15 different options (not an exaggeration). The doctor agreed that we should try Prednisolone to see if that would help. So, he has been taking 5mg per day and today will be day 3. I am aware that this could alter biopsy results, but I haven't fully decided if we should do that or not and he needed some help now, not later. Out of desperation, I made another trip to the pet store and bought some various foods, including some of the gasto prescription lines. Shockingly, a little while after I gave him Prednisolone, he gobbled up an entire 5.5oz can of the Purina Pro Plan Veterinary Diets EN Gastroenteric Savory Selects in Gravy and I've been able to get him to eat a can and a half (plus or minus a little) per day since then, which is great! I've still tried to offer him the foods he use to eat as we have two other cats that are still eating the other food and he turns up his nose at them. He is still very lethargic and doesn't do much moving from his nap spot. He is still sleeping on or next to me at night and purring his little heart out.

What I'm wondering is, does this really sound like IBD to you? It doesn't even sound like lymphoma or the other GI thing our other cat had. With the kitties we lost, it was a lot of vomit, constipation or diarrhea. But with this cat, he only had a small amount of diarrhea at the tail end of his poop, where it was solid before that. I forgot to mention, I'm also giving him a daily probiotic (Proviable-DC as he won't eat the Forti Flora). Since he got home from urgent care, his poop has been completely formed (he has no history of diarrhea prior to this last weekend and it was only twice). He has only vomited maybe once per week to once per every two weeks even, for the last month or so. We thought any vomiting was related to needing to up his thyroid med. He has also lost a bit of weight, he is in the 8-9 pound range currently and we had also thought it was his hyperthyroid meds needing to be upped that caused this previously. Otherwise, he has had zero vomiting since right before urgent care. What I'm guessing is, what I thought was him being picky is just that the foods were not making him feel well and so he would stop eating it and leave me to find something else for him. Does this sound like anything else or could this still be IBD? I know every cat is different and so one cat may not have the same symptoms as another cat, but I just see so much information about vomiting/diarrhea, that it seems weird that our cat has really had very little of this behavior. Or is it just that anorexia is his main symptom? Has any one else had a similar experience? I'm happy to post his labs and his ultrasound results, if that would help. So sorry for the long winded post.

 

[Furballsmom]

we had also thought it was his hyperthyroid meds

Hi, welcome!
I apologize, I didn't see that you said how much of a dose of Methimazole he's getting? Just to mention, are you having his T4 and possibly the free T4 numbers checked before you increase the med?

My concern is that the med may be causing issues;

My cat was diagnosed with hyperthyroidism in July. We immediately started her on Methimazole and her thryoid levels quickly regulated. However, after about a month of treatment she developed extremely high liver enzymes along with vomiting, refusal to eat, and noticeable pain. After stopping the methimazole, this fixed itself quite quickly.

Actually, the entire thread that this post came from could be a worthwhile read for you.
Methimazole Alternative for Hyperthyroidism

Have you considered the Hills y/d thyroid prescription food? The kibble is in stock on Chewy as of today.

 

[fionasmom]

IBDKitties – Helping Save Lives…One Paw at a Time
There might be some information here that will help to answer some of your questions.

 

[FeebysOwner]

Hi. No apology needed for the length of the post - sometimes I respond to some of them with even longer ones (may be the case here too)!!!

Yes, cats will vary in terms of their symptoms - to any disease or illness they might have. So, all I can do is tell you a little bit about my 18+ yo cat who is hyperthyroidic, has CKD, and arthritis, and was just recently diagnosed with SCL - small cell lymphoma (enlarged intestinal lymph nodes).

It took 3 ultrasounds, two fine needle aspirations (FNA), and finally a PARR assay to determine the SCL - the last set of testing was done 6/2022. I wasn't willing to put her through a biopsy. The FNAs analyze tissue that can be collected to look for abnormal cells - Feeby's was inconclusive. So, that is when with the 2nd FNA I asked for a PARR assay, which is a more in-depth analysis of the tissue collected with an FNA. That is when the SCL was identified. It is believed to very early stage and she is not yet being treated.

She doesn't vomit, has good stools, and did not have any thickening of the intestinal wall - all of which are pretty common with IBD, but they still wouldn't rule it out until that PARR assay was done. You might consider another ultrasound/FNA, and a PARR assay if the FNA comes back inconclusive. The labs usually hold tissue aside for at least a week or two, so a follow up PARR can be done after the fact.

Nonetheless, Prednisolone is generally used as the first line of defense in either IBD or lymphoma. If it doesn't reap good results, many vets will add or move on to chlorambucil (chemo) without confirmative diagnosis of lymphoma.

Feeby is a ridiculously picky eater - started before the first ultrasound (8/2021). She cannot seem to eat the same thing twice in a row, sometimes if I give her 2-3 weeks in between tries she might eat it again - sometimes not ever again. She is on - and has been for a while now - Mirataz (1/2 dose every other day) an appetite stimulant, and ondansetron, which is an anti-nausea med (4mg twice a day). The Mirataz seems to help, but not sure about the ondansetron. I keep her weight maintained by adding baby food meat to her daily food - you can buy a nutritional supplement called EZ Complete that can be added to any of the baby food meats other than chicken (too much calcium) to make them nutritionally complete for a cat. While she won't repeatedly eat the cat foods, so far, she hasn't turned down the baby food meat (knock on wood).

Lastly, I want to talk about the hyperthyroidism - after 2 1/2 years since diagnosis, Feeby's current dosage of Felimazole (cat version of methimazole) is 1.875 mg twice day. And, I don't have her dose changed without a T-4 test being run first, and then again 3-4 weeks later after any dosage changes. As mentioned above, a too high of a dose can cause its own set of problems. It is also important to note that CKD cats usually do better with a T-4 that runs a bit higher than an otherwise healthy cat should have. For illustration purposes, we upped Feeby's dose to 2.5mg AM/1.875mg PM and her T-4 went down to 1.3 - in an otherwise heathy cat, this is good. In a CKD cat, their bodies function better with a T-4 between 2-3. [These numbers are based on the associated lab ranges of 0.8 - 4.0. and can vary based on the lab that processes the blood work.]

So, in reciprocate - sorry for the long response!!

 

[Mac and Cats]

Hi, welcome!
I apologize, I didn't see that you said how much of a dose of Methimazole he's getting? Just to mention, are you having his T4 and possibly the free T4 numbers checked before you increase the med?

My concern is that the med may be causing issues;


Actually, the entire thread that this post came from could be a worthwhile read for you.
Methimazole Alternative for Hyperthyroidism

Have you considered the Hills y/d thyroid prescription food? The kibble is in stock on Chewy as of today.

Hi! Thank you! Yes, we have his T4 checked regularly and I would not mess with his dose otherwise if we had not had them checked. He takes 2.5mg in the morning and 5mg in the evening. I have not read that thread, but will read it today. We have had full lab work ups done a few times over the last year and the last 3 labs have come out with everything normal (kidneys, liver, etc.). We have not tried the Y/D, but I'm not sure it would work very well for us to begin with. I have heard of it, but I guess I never considered it because I haven't heard very many success stories with it. I will ask his doctor about it this evening when we have our phone call and see if she thinks the medication could potentially be causing it. We also have 3 cats total and it's really exhausting to keep them out of each others food. After losing 3 cats in a span of 18 months and dealing with multiple pills/different foods/etc. It's not something I really want to consider, but of course I would give it a try if our doctor thought it would be worth a try. We actually have two cats with hyperthryoid, so I suppose we could discuss trying it with both of them. I will look into reviews on the Y/D as well to see if I can find any success stories. He eats only wet food and has zero interest in dry food. I did look into the Iodine radiation treatment, but then our other elderly cat was also diagnosed with hyperthryoid and it was sort of like, well how do we decide who gets it and who doesn't? Especially since we really can't afford it anyway.

I also forgot to mention that he also takes Prozac daily, which we will be doing a trial of weening him off of it. The reason we put him on this to start is because he was spraying everywhere when we first got him and then our other cat started spraying everywhere too. I tried EVERYTHING you can possibly imagine (extra litter boxes, litter boxes in other areas of the house, different litter, pheromones, etc. etc. etc. It was my very last resort and it worked immediately. He stopped spraying the day he started taking it. I will be talking with the doctor about that this evening as well. Thanks so much for your suggestions and your reply!

 

[Mac and Cats]

Hi. No apology needed for the length of the post - sometimes I respond to some of them with even longer ones (may be the case here too)!!!

Yes, cats will vary in terms of their symptoms - to any disease or illness they might have. So, all I can do is tell you a little bit about my 18+ yo cat who is hyperthyroidic, has CKD, and arthritis, and was just recently diagnosed with SCL - small cell lymphoma (enlarged intestinal lymph nodes).

It took 3 ultrasounds, two fine needle aspirations (FNA), and finally a PARR assay to determine the SCL - the last set of testing was done 6/2022. I wasn't willing to put her through a biopsy. The FNAs analyze tissue that can be collected to look for abnormal cells - Feeby's was inconclusive. So, that is when with the 2nd FNA I asked for a PARR assay, which is a more in-depth analysis of the tissue collected with an FNA. That is when the SCL was identified. It is believed to very early stage and she is not yet being treated.

She doesn't vomit, has good stools, and did not have any thickening of the intestinal wall - all of which are pretty common with IBD, but they still wouldn't rule it out until that PARR assay was done. You might consider another ultrasound/FNA, and a PARR assay if the FNA comes back inconclusive. The labs usually hold tissue aside for at least a week or two, so a follow up PARR can be done after the fact.

Nonetheless, Prednisolone is generally used as the first line of defense in either IBD or lymphoma. If it doesn't reap good results, many vets will add or move on to chlorambucil (chemo) without confirmative diagnosis of lymphoma.

Feeby is a ridiculously picky eater - started before the first ultrasound (8/2021). She cannot seem to eat the same thing twice in a row, sometimes if I give her 2-3 weeks in between tries she might eat it again - sometimes not ever again. She is on - and has been for a while now - Mirataz (1/2 dose every other day) an appetite stimulant, and ondansetron, which is an anti-nausea med (4mg twice a day). The Mirataz seems to help, but not sure about the ondansetron. I keep her weight maintained by adding baby food meat to her daily food - you can buy a nutritional supplement called EZ Complete that can be added to any of the baby food meats other than chicken (too much calcium) to make them nutritionally complete for a cat. While she won't repeatedly eat the cat foods, so far, she hasn't turned down the baby food meat (knock on wood).

Lastly, I want to talk about the hyperthyroidism - after 2 1/2 years since diagnosis, Feeby's current dosage of Felimazole (cat version of methimazole) is 1.875 mg twice day. And, I don't have her dose changed without a T-4 test being run first, and then again 3-4 weeks later after any dosage changes. As mentioned above, a too high of a dose can cause its own set of problems. It is also important to note that CKD cats usually do better with a T-4 that runs a bit higher than an otherwise healthy cat should have. For illustration purposes, we upped Feeby's dose to 2.5mg AM/1.875mg PM and her T-4 went down to 1.3 - in an otherwise heathy cat, this is good. In a CKD cat, their bodies function better with a T-4 between 2-3. [These numbers are based on the associated lab ranges of 0.8 - 4.0. and can vary based on the lab that processes the blood work.]

So, in reciprocate - sorry for the long response!!

Thanks so much! It helps to hear other stories. I for sure would not change his dose without a T4 test and without doctor instruction. We did a T4 test on him to confirm that his dose needed to be moved up. His T4 at the end of December (about a month after we had raised his dose) was at 1.9. His kidney values have been within normal range the last 3 labs he has had done. The most recent at the urgent care, his BUN was 19, PHOS 3.4 and CRE 1.2. I'm not super knowledgeable in the numbers and what they should/shouldn't be, but from my understanding those are all supposedly good numbers. I think I will feel better after talking to his primary doctor this evening. The reason we have a secondary doctor is because sometimes in an emergency, we just can't get them in quick enough to our primary doctor. The secondary doctor is much more expensive or we would just switch completely. Although, we do really like his primary doctor a lot and she truly helped us when we were going through losing our 18 year old CKD cat back in 2021. Thanks so much for your reply! It is so helpful to hear other's stories.

 

[Mac and Cats]

IBDKitties – Helping Save Lives…One Paw at a Time
There might be some information here that will help to answer some of your questions.

Thank you! I was looking at that site yesterday and it did help answer some questions I had previously.

 

[FeebysOwner]

If you have copies of the lab reports, they will show you the ranges so you can see where your cat's numbers fall. Using the numbers you have when compared to my lab reports (Antech), they are good. My vet would not even consider it early CKD based on your cat's creatinine number - using the ranges I am familiar with. It must be something perhaps that showed up with a urinalysis? A low USG (urine specific gravity) is often used as one of the elements to gauge CKD.

I am glad you are OK with hearing other cat's stories but hope you can still glean some benefit from mine in some way.

 

[kjc1020]

Hi, I'm the one who posted the original thread about the methimazole alternative for hyperthyroidism. Lots happened since then, but short summary--

My vet was willing to do a blood test that went off to a company (I can't remember the name at the moment) to test for IBD/lymphoma. My cat's came back as likely lymphoma, could be severe IBD. My vet was comfortable treating her as if lymphoma without a biopsy, thankfully. We started her on high dose prednisolone 2x/day and within about 48 hours on that she started eating again. That was back in October and we have weaned her down to 1x/day at a lower dose. It's a bit higher than I'd like, but each time we wean she flares, so vet decided to keep her there. We also went ahead and started Chlorambucil 3x/week right away, acting as if was lymphoma. She has had an occasional vomit issue since then and days her appetite is a bit off, but generally is so much better!

At that point, we felt like all her symptoms of vomiting etc were from IBD/lymphoma not the hyperthyroidism so we took a wait and see approach with the thyroid, since her levels weren't super high--around 5, I think. I had her in last week and her blood work all looked great, but her thyroid levels were coming up (8-ish) and her weight had dropped about a half pound since Oct--I had also noticed she was a but grumpy so I suspected thyroid was getting worse. My vet feels like the Hills Y/D is our only choice for thyroid as she can't have methimazole and isn't a good candidate for iodine or surgery. So, I just started her on the Y/D about a week ago. She likes the dry, and then is getting a small can of Weruva split over two meals since the wet Y/D is out of stock. I'm hoping that will be good enough to get the thyroid under control....if anyone has a sense of how much Weruva is too much, I'd love to know.

In general though, all her vomiting, poor appetite etc seems to be mostly from IBD that was exaggerated by the methimazole that did a number on her liver. I was really considering in the fall if her quality of life was good, but steroids have been massively helpful for her.

I hope that helps!

 

[Mac and Cats]

If you have copies of the lab reports, they will show you the ranges so you can see where your cat's numbers fall. Using the numbers you have when compared to my lab reports (Antech), they are good. My vet would not even consider it early CKD based on your cat's creatinine number - using the ranges I am familiar with. It must be something perhaps that showed up with a urinalysis? A low USG (urine specific gravity) is often used as one of the elements to gauge CKD.

His levels were higher previously, when we first adopted him. Both vets have now said he is no longer in the early CKD stage since the numbers have come down. When we first got him back in early 2021 his levels were: BUN - 41, CREA - 2.100, PHOS - 6.1. So, they have come down significantly since then.

 

[Furballsmom]

if anyone has a sense of how much Weruva is too much, I'd love to know.

I'm going to think out loud here, if I understand your question correctly, that probably the best approach would be to test the T4 and also possibly the free T4 and T3.

 

[Mac and Cats]

I hope that helps!
[/QUOTE]

That is helpful to know, thank you! I will look into other reviews/stories about that and get our doctor's thoughts on it. That is a huge bummer that they are out of the wet Y/D. Have they been OOS for a long time? Unfortunately, our cat won't even touch dry food or give it a first glance. We do put dry food out to supplement for our other kitties and he won't touch it. I've offered it to him before in a few different varieties, but he has no interest. So, I guess we would be out of luck until that was back in stock anyway. Thanks so much for sharing your story with me!

 

[Furballsmom]

wet Y/D. Have they been OOS for a long time?

It's been inconsistent regarding when the two thyroid products made by Hills have been available. The manufacturer has told me that they're building another facility this year in order to be better able to keep up with demand.