4/13 Jenks AMPS 116 +3 69 +5 84 PMPS 112 +7 106

4/12

Jenks began last night pretty well. He ate a good bit of his dinner unassisted, and then a little more with FortiFlora. Lately, his PM cycles have been pretty mild, but tonight he decided to drop a little too low and throw out a 41, which was then further complicated by the fact that he didn't want to eat either of the two cans of food I put out or even the high carb gravy with karo. I ended up having to syringe feed the gravy, much to his chagrin. I must've been a little heavy-handed with the karo because you can see the resulting number, but I don't care because it was essential to get him into safe territory with plenty of buffer should he decide he didn't want breakfast food either.

AMPS rolls around and his numbers are stable. He didn't want to eat much at breakfast either, but I was able to entice enough with some parmesan cheese to go ahead with a shot.

We're about 10 days post vomiting/diarrhea/metronizadole and the appetite still hasn't returned. I'm doing everything I can: trying a variety of flavors, adding natural enhancements, slippery elm bark, even the occasional massage (for him, not me hah!).

Currently, his appetite is hit or miss. It's unusual for him to shun gravy and karo. But he still perks up and eagerly goes for dry treats. I'm not sure what accounts for the difference.

We're going to call the vet today and see if he'll consider giving us an appetite stimulant. Right now, our priority is getting him eating before we move on to whatever is next. I've read a number of discussions about cyproheptadine vs. mirtazapine, and the consensus seems to be cypro > transdermal mirt > pill mirt in terms of side effects and potential for serotonin syndrome. Am I correct in my understanding? Is one more effective than the other in stimulating hunger? This assumes, of course, that the vet is (1) amenable to prescribing one and (2) willing to offer a choice.

There was a lot of stuff happening in yesterday's condo that I didn't get to, but will try to respond to here later this afternoon.

In the spirit of continued discussion and information gathering & sharing, here are some more interesting sources on creatine kinase that I've run across in the last 24 hours while trying to educate myself on the subject:

http://www.the-vet.net/DVMWiz/Vetlibrary/Lab- creatine_kinase.htm
In my opinion, a much better-written and more comprehensive informational source than the one included in the IDEXX manual. Among other things, it has a useful section on diagnosis.

Of particular interest is this statement:

"Aspartate transaminase (AST)--if increased without evidence of liver disease supports the diagnosis of muscle disease"

In Jenks' bloodwork, AST and CK are high, but ALP and ALT are normal.

https://web.archive.org/web/2013050...t.cornell.edu:80/clinpath/modules/chem/ck.htm
Cornell Veterinary University page about CK, including some interesting stuff about its biochemistry.

https://www.felinecrf.org/diagnosis_blood_chemistry.htm#creatinine
Tanya's site notes:

"If levels are high, it may indicate some kind of muscle disease; alternatively, very high levels of CK are often seen when an animal has heart issues. If your cat's level is over 1800, your vet should investigate further."

In contrast:

http://www.vetinfo.com/cfeleuk.html
An older link, but with an interesting. albiet unsourced, discussion buried in the middle of a bunch of questions about feline leukemia of all things. Relevant portion bolded:

"High CPK (creatinine phosphokinase) levels in cats occur for several reasons. There are numerous reports of high CPK levels in the absence of any identifiable disease, too. That may be because of diseases that are hard to find or there may be some problem associated with CPK that we just don't know about. The identified causes of CPK rises in cats are muscle damage, anorexia (not eating), inflammatory bowel disease and pancreatitis (possibly due to intestinal muscle damage, possibly due to not eating associated with these diseases), cardiomyopathy (again due to muscle damage), thromboembolisms (also probably due to muscle damage it causes in rear legs) and a genetic disorder in a research colony of cats with dystrophin deficiency. The CPK value can get into the hundreds of thousands and is commonly in the thousands just from not eating, apparently. This makes it a little hard to figure out how significant a rise in level is. It is still worth looking for any cause of muscle damage, checking for heart murmurs, making sure your cat is eating OK and thinking about pancreatitis. The TLI (trypsin immunoreactivity like) serum levels may be high with pancreatitis and somewhere I think I have read about an increase in pancreatitis in cats with FeLV, so that is another thing you could check out. Monitoring weight over the next month or so would be a good idea, too. As with all testing, lab errors sometimes occur, too. It might not be a bad idea to recheck the CPK level just to see if it remains high."

 

Looks like I'm up for just a bit longer, so I'll get to those replies right now instead of this afternoon:

Continued thanks to everyone who stopped by with support and information, it's immensely helpful.

@Stacy & Asia - Great info on CardioPet ProBNP vs. SnapBNP. I'll need to do some more reading, but to me there doesn't seem to be a compelling need for a specific levels value to choose the Pro over the Snap, especially since an echo is the recommended next step for an abnormal value on either test. My vet mentioned how rarely he orders the comprehensive IDEXX blood panel for cats, so I'm not sure how familiar he'll be with either of these.

@carfurby - Keep those positive thoughts coming! I think they're helping him eat better!

@LizzieInTexas - Very informative document! Thank you for sharing it. It will help make the decision on a blood test if we have to make that choice.

@PussCatPrince - Thank you for your healthy appetite vines! They're special because they're foreign

@Marje and Gracie - Thank you for taking the time for that very detailed response. Focusing on the CK portion:

I need to clarify that there was no notation about hemolysis in the report, not that there was a notation that said hemolysis was not present. I'm not sure if that is significant.

• Jenks is a ground cat, so I can guarantee he hasn't fallen from any height.
• He and his brother occasional box or wrestle. I can't observe everything, but from what I've seen, I feel pretty safe drawing a conclusion that it's never been rough enough to cause any sort of injury.
• At the start of July 2017, he did have that issue of the mysterious limp tail. But it recovered quickly and has remained normal ever since with no signs that it, or anything near is is troubling him.
• My thoughts echo yours re: intramuscular injections.
• Weight loss was on the year was more or less 29 to 26 pounts, so about 11%. I can't find any notes in my notebook or spreadsheet to see if I have any at-home weights for him between those two annual vet visits to say how fast or slow it happened. I'll keep looking.
  
• Agreed re: immune cells. The ones that are elevated are only by a margin of 10-20%.
• I agree that the weirdest part of all of this is that he's having the best blood sugar readings of his life on the lowest dose in four years. I would expect that to not be the case if there was something systemically wrong.
• The more I hear about the cardio blood tests, the more I think it may just be more worthwhile to do an echo. But I say this not knowing the costs of any of those options. Yours is the second recommendation for Dr. Church. They're nearby, and Jenks has already been there for his last major dental, so that's always a plus if we need them.
• As for the vet not mentioning it, all I can think of is that he may not be very familiar with it. He did mention that he hardly ever orders a comprehensive IDEXX panel for cats. It may be something he just hasn't seen, thus my attempt to rapidly come up to speed on the topic.

 

Very likely, and good on you for being informed, it will only stand to benefit Jenks.

Many of the lab values don’t really mean anything on their own without other things to tie them too, especially symptoms. I find a common approach for vets is to ignore certain values (even if they could mean something that can be discovered with more digging and diagnostics) in favor of not unnecessarily worrying the caregiver and letting the cat be until such time that labs are repeated to see if it is a fluke and/or other symptoms develop. Unfortunately, this approach does mean things slip through the cracks and could mean something has to get pretty bad, sometimes even irreversible, before it is officially diagnosed and addressed.

My take is that you have to weight the level of complications here, if you were dealing with a young and otherwise healthy cat, that would be one thing. FD is a major complication to all organs when numbers are outside of the euglycemic range (which we assume here is 50-120 on a human meter). In addition to this, it is highly suspected Jenks has a high dose condition, the condition itself is a complication and not knowing which condition it is, an additional complication. For example, IAA is self limiting, outside of what damage is caused by the high numbers until it is overcome, it is somewhat benign and will resolve without you doing anything other than giving enough insulin. Acro, on the other hand, is progressive and is known to cause many problems, including heart ones. If you have a diagnosis of acro say, you could give cabergoline or seek a more aggressive form or treatment (or not) and try to manage it as best you can. Given these things, it’s easy to go with: investigate the CK furthe over dismiss it like the vet did. Whether that means a snap BNP now and an echo soon down the road, or waiting a short length of time for appetitite to increase and repeating labs to see if the number comes down, or just going to get an echo, that’s up to you and your situation.

I was looking for my itemized receipt for the snapBNP (positive/negative) and I cannot find it right now, but off the top of my head, it was around $90, also I’m in NYC and everything here is overpriced, I don’t know if the prices are set by IDEXX or by the vet, I would suspect the latter, so it may cost less for you.

I have not had to use an appetite stimulant on Asia yet, touch wood, but I do have cypro on hand and requested it specifically over mirtz for the reason you mention, your vet likely would not give you a choice, but should oblige if you request it by name so long as he is familiar with the two. Also, no experience with this whatsoever other than seen a few on the board prescribed it. There is a new appetite stimulant for cats called Entyce? Might want to read up on that as it is another option, and if it turns out to sound like a bad option and your vet recommends it, you can have the background to make an informed decision about it.

More vines for Jenks. Come on Jenks, eat your foods and feel better!

 

Pretty standard day number-wise, but the appetite is still anemic. He didn't want to eat the midday meal, and ate just ok at PMPS dinner. I got him to eat a little more by crushing and sprinkling a couple dry treats on top of the food. Strangely he still perks up and wants to eat the dry treats, even when he's shunning the wet food. It's weird.

We spoke with the vet today.

Good news: he prescribed an appetite stimulant without needing an office visit
Not-so-good news: It's mirtazapine. Despite best efforts, he wasn't amendable to alternatives, so it was this or nothing, and we can't afford to do nothing.
OK news: It looks like he at least got the dosage right. One-quarter of a 7.5mg pill, which is the 1.8mg dose recommended in the literature to minimize potential side effects.
Angry news: He's not concerned at all about the creatine kinase. His explanation was basically, that's what happens when they don't eat. I find that response completely unsatisfactory, and I'll try to broach the subject again next week.

I didn't get the stimulant of choice. I don't like hand-waving in response to my concerns. I'm getting unexpected pushback on this whole thing from OH. I just want to take care of Mr. Jenks and I frankly don't care how much it costs or what I have to do to get it done. But I'm feeling like I'm alone, and subsequently powerless, in that sentiment, and it sucks.

Ok, that's my "woe is me" moment. Now back to business.

Mirtazapine question
What the heck do I do with this anyway? The instructions say one-quarter of a pill every 24-48 hours as needed to stimulate appetite. Does that sound right? How do I tell if I need to do it daily or every other day? How far in advance of a meal should I plan to give it to him?

This article in American Veterinarian journal notes:

"Current dosing recommendations for mirtazapine in young, healthy cats is 1.88 mg/day. In older cats and those with chronic kidney or liver disease, 1.88 mg can be given every 48 hours."

Sooooo, every other day for Jenks?

 

The latest research on mirtazapine published in the ACVIM Conference paper in 2017, is that it only lasts 9 hours in the cat. That same article is the one that recommends transdermal to lesson side effects. In pill form, I would do every day if needed.

I would avoid Entyce like the plague. One effect of it is to stimulate growth hormone production, more of which is not needed in an acrocat or suspected one.. I have seen one person try it here, with little success as an appetite stimulant.