diltiazem side effects and hepatic function?

[faranya]

My five-year-old neutered male cat was diagnosed with early cardiomyopathy in mid-May, after four years of normal routine checkups (the last one in October). His heart x-ray revealed a heart of normal size, so the diagnosis was made on the basis of an elevated heart rate (200). He also had cold feet, perhaps from blood clots. He didn't suffer from major symptoms, however; I recognized that he seemed to be somewhat less than his usual happy self and acted accordingly, but a casual observer would not have said, "This is a sick kitty."

He was immediately put on 30 mg diltiazem per day in tablet form, which was increased to 45 mg. As well, he was given a course of lasix, together with baby aspirin in very low dose. Ultimately this was discontinued. He was also prescribed Clavamox, which was renewed when the first course ran out.

Follow-up blood work revealed what appeared to be kidney impairment, so the vets assumed that there had been some renal problems owing to clots. We began subcutaneous saline injections (30cc twice daily) which I did at home, plus a potassium supplement. The saline was later cut back to once every other day, about ten days ago.

But little Gollum's appetite has plummeted since he took his first diltiazem. He's gone from almost 14 pounds to just over 10. He's always loved to eat but now he just licks at it, making a game attempt to please me. He is clearly anorexic and seems nauseated off and on. Follow-up blood work last Friday showed kidney function is now normal in all respects (!) but hepatic function has been disrupted - and that was normal earlier. I don't have the readings, however. My vets then put Gollum on a week's worth of liquid pediapred (3 ml a day), as the liver area felt tender to the touch. He also got another round of Clavomox which ends tomorrow. The prednisone finishes Saturday. He's also on 30cc of the subcutaneous saline, three times a day, and potassium capsules (234 mg). six per day. His diltiazem is now administered inside his ears, since he's being asked to swallow so many other things. The poor little fellow is enduring something like fifteen different doses and injections each day!

Needless to say, he looks and acts really depressed about life. He's gone from a happy-go-lucky adventurer on our 4 1/2 rural acres to a dull, miserable huddler in a corner. He still wants to go outdoors and is walked regularly so he can pee in the grass. He has no bowel movements to speak of (although he did have one in his carrier coming home on Friday), as he's ingesting only pureed foods turned into soup (liver, low-sodium salmon or tuna, pricy little tins of wet cat food). I added a bit of olive oil to this evening's puree in the hope of incorporating extra calories and some good fatty acids.

So my question is this: is it possible the diltiazem is causing this appetite loss? My vets are terrific folks so I hate to press the point. But when I asked them, they told me the drug hadn't caused this kind of problem for other patients. Yet I've done research which indicates it's a culprit in anorexia, vomiting and even hepatic complications.

If anyone can offer some added insight here, I'd be most grateful. We have another appointment with the vets who, needless to say, know us rather well by now. But I was wondering how to tactfully revisit this issue. I've come across the drug atenolol in my reading and am wondering whether it might be a viable alternative. The Incredible Shrinking Kitty sure does need that!

Thanks to anyone who can make any suggestions. I'm financially strapped now, as I'm a retiree on a fixed income, and emotionally I don't have much to work with. I can't afford to keep pursuing treatment options that might make the situation even worse for my cat. Nobody wins in that case. Yet I also want to do right by him. He's a sweetie who deserves it.

[sugarcatmom]

First of all, welcome to the board and I'm so sorry to hear about Gollum's problems. I have an HCM kitty myself, so I understand your worry. He's currently on Atenolol and doing great, even showed improved cardiac function on a follow-up echocardiogram. Has Gollum ever had an echo, or just the x-ray? Even though they're really expensive, they are the best way to figure out exactly what's going on with the heart and when you can afford it, I'd recommend investigating that option if possible.

As for the diltiazem, I don't have any personal experience with it so can't say if it would be responsible for Gollum's inappetance. HOWEVER, I do know that Clavamox is legendary for causing digestive upset in cats, so I'd be more suspicious of that as the culprit. Why was he put on antibiotics anyway?

The liver issue is serious and at this point you must do everything to get him to eat, syringe feeding if necessary. Hepatic Lipidosis is often the result of anorexia in cats and the cure is high protein food. Many times it's necessary to put a feeding tube in to ensure that the cat gets enough nutrition. Has the vet mentioned using an appetite stimulant at all? Also, your vet's prescription of pediapred might be a concern, as this previous post by our resident (and fabulous) Dr. Lee indicates: http://www.pets.ca/forum/showthread....sis#post600782

I would be concerned about the use of steroids with hepatic lipidosis. This is from a feline internal medicine specialist, "Glucocorticoids (prednisolone)result in the mobilization of peripheral fat stores -- this is something that you do not want to do with hepatic lipidosis." - Michele Gaspar, DABVP (Feline). Mobilizing peripheral fat stores can make hepatic lipidosis worse!

I hope Gollum recovers soon! Please keep us updated.


ps - Just wanted to add that Atenolol is tasteless and easily mixed with food, so it's very easy to administer if you have any concerns about that.

[growler~GateKeeper]

Originally Posted by faranya

he's ingesting only pureed foods turned into soup (liver, low-sodium salmon or tuna, pricy little tins of wet cat food). I added a bit of olive oil to this evening's puree in the hope of incorporating extra calories and some good fatty acids.

Just wanted to mention if the olive oil doesn't work you can try a little melted no salt added butter or catnip on top of the food to entice eating

for Gollum

[faranya]

Thanks so much! You've provided a wealth of information.

An echocardiogram was not even mentioned; we're a small community here, and this is not a big clinic either. I wouldn't be surprised if they didn't have this particular test available, because they've certainly apprised me of everything else. I can inquire, though.

I'm not sure of the reason for the Clavamox in the first place. It was just prescribed, then extended. The vets were shocked that this was happening because they'd done all the routine checkups since Gollum was a baby fresh out of the SPCA and there was no sign of anything amiss. So they may have chosen to err on the side of caution to prevent infection, or battle one already present that might have contributed to the situation. As I said, Gollum didn't even appear ill, so the cause will remain a mystery.

The latest dose came after the liver function tests showed elevated levels of bilirubin, plus anemia, that might have resulted from an infection. Ironically, when G. was taken out for one of his walks, he ducked off the driveway and immediately caught a vole - took him 20 seconds! - and the feisty critter tried to bite at him. So there might have been a question of a vole-borne virus or bacterium. I think it unlikely, though. Gollum was feeling poorly before that happened. And he's captured dozens of luckless voles in his short life.

I asked about a "tonic" to stimulate appetite but no, there was no mention of a stimulant per se. The pediapred is finished Saturday; I doubt it will be renewed.

I'm very tempted to take him off the diltiazem briefly - only a day or so - just to see if his appetite picks up. According to the research I've been reading, this often happens and indicates a drug sensitivity. I will ask about atenolol as an alternative since I'll be touching base with the clinic tomorrow (today, now it;s past midnight). I would rather see him enjoying what's left of his life, even if shortened by a few months, than enduring a series of treatments and injections and pills that only increase his misery, and can't cure him.

Thanks again! I really appreciate the help.

[faranya]

Update: we went to the vet yesterday and I was fully expecting him to recommend euthanasia owing to continuing loss of weight, and general miseries. Gollum's mucus membranes showed jaundice - no surprise. He's still losing weight as well. His heart rate was over 200. The vet is mystified as to what has caused all this. The Clavamox had been intended as a measure of managing red blood cell destruction, which could have resulted from infection. I asked him about the diltiazem and even showed him a printout of a study implicating the drug in weight loss, nausea and refusal to eat. However, Gollum is being treated with the suspension in a cream I rub inside his ears (30 mg per day), and apparently this has fewer side effects.

Anyhow, we discussed options while Gollum purred, and then the vet did a hematocrit to determine the continuing extent of the anemia. Last Friday the red blood reading had been a dismal 15. When he called me back into the exam room, I figured he was going to tell me it was time to put Gollum down. Instead, he showed me the pipette in which the blood was a deep red, with a count of 24! It had risen nine points in six days. We were both amazed by this. That pureed raw beef liver must've been really something. First sign of improvement since the kidney function returned to normal.

My vet is a very attentive person, and takes a lot of time with me whenever I bring Gollum in. He's also available for questions by phone anytime I have concerns. When there's an emergency he's there. If he isn't, his brother - also a vet - is. They've always done well by me, over the past fifteen years or so. He was willing to set me up with all the supplies and meds needed to provide care over the next while, so I wouldn't have to keep making the 40-km drive to and from the clinic. A family medical situation is complicating things as well.

So now Gollum has a reprieve and I'm back to home nursing. Clavamox has been cut back to one a day for the next week. Pediapred is still being given at 2 ml twice a day, for one more week - it does seem to stimulate appetite to some extent and that's the trade-off, I suppose (but yes, I do worry about its effect on the liver). I'm still injecting sub-Q saline 3x daily, with potassium capsules and/or mashed banana pureed with some water and dosed into the mouth. Diltiazem is still being given as well. I mentioned Atenolol, but the response was neutral because he felt the diltiazem was probably more effective in this particular case. He also gave me some very moist, vitamin A/D medical diet wet food, which I've been feeding pureed with a bit of water. The raw liver is still "on" as well. I remain guardedly hopeful that our joint efforts will have at least mildly positive results. It's a labor-intensive course of therapy, for sure.

Gollum is no longer drinking at every water source he sees. If anything, he's not drinking enough ... but perhaps the pureed wet foods and fluids are now doing their job. He still pees rather well. When he was healthy, I don't recall him as an excessively eager water drinker, except in strange places like my little fish pond, so maybe this is a good sign. He hasn't vomited since Monday. Last night as I was gardening and happened to walk across the lawn, dragging a piece of baler twine I'd untied from a bag, I felt a tug on it. He had started to give chase (although slowly) and was attempting to play with the twine!

I want to say thanks again for the information and encouragement. What a great site this is! I'm so glad I discovered it.

Brenda

PS - The melted butter sounds like a neat trick. Gollum is one of those weird catnip-indifferent kitties, though.

[sugarcatmom]

Originally Posted by faranya

Diltiazem is still being given as well. I mentioned Atenolol, but the response was neutral because he felt the diltiazem was probably more effective in this particular case.

Just so you know, there are many factors that influence the absorption of transdermal meds and because there haven't been all that many studies on their use in cats, you might want to try to monitor Gollum's heart rate at home (easier said than done!) to make sure the diltiazem really is doing it's job. The fact that his heart rate is still over 200 is a bit concerning.
http://www.wedgewoodpharmacy.com/mon...dermalGels.asp
http://www.vin.com/proceedings/Proce...C2003&PID=3673

Originally Posted by faranya

He had started to give chase (although slowly) and was attempting to play with the twine!

Yay!! That is a very good sign. that his spunkiness keeps improving. Also, not sure if you saw my post regarding syringe feeding in the Clavamox thread, but just in case: http://www.pets.ca/forum/showthread....ing#post616731

[sugarcatmom]

Totally forgot in my last post to mention a couple of supplements that you might want to talk to your vet about. The first is Denamarin, which contains SAMe (denosyl) and silybin (extract of milk thistle). It has proven liver boosting capabilities.

Also 250mg per day of L-Carnitine can help with liver issues and is often used in cases of hepatic lipidosis. There's a ton of technical stuff at this link related to treating HL: http://www.vin.com/proceedings/Proce...5828&O=Generic

As for food, depending on if you have to syringe feed Gollum, a better option than Hill's A/D (for "anorexia diet") might be Eukanuba Maximum Calorie. The A/D is 180 calories per can, while Maximum Calorie is 340 cal/can. You get more bang-for-your-buck, so you can feed less in volume. Here's a quote regarding the importance of nutritional therapy in treating liver problems: http://maxshouse.com/Feline_Hepatic_Lipidosis.htm

The cornerstone of therapy, the only way to reverse the process of fat accumulation in the liver, is aggressive feeding to supply your cat with his or her full caloric requirements. Offering different diets and appetite-stimulating medications may induce a cat to eat in the initial phases of anorexia but will most likely not be of benefit once clinical signs of hepatic lipidosis develop. Appetite stimulating drugs, such as benzodiazepines (diazepam [valium], oxazepam) and cyproheptadine (Periactin), are primarily effective for stimulating appetite in those cats that are only partly anorectic, that continue to show some interest in food (even if not eating), and that are not severely ill.

[growler~GateKeeper]

Originally Posted by faranya

That pureed raw beef liver must've been really something. First sign of improvement since the kidney function returned to normal.

PS - The melted butter sounds like a neat trick. Gollum is one of those weird catnip-indifferent kitties, though.

So glad Gollum is turning around

I would keep up with the raw beef liver - there are lots of good nutrition in liver, & more so in beef for kitties. Even better I think it would be good to give raw pureed beef muscle meat with beef liver as a one small meal or a treat each day, if you can, for the next while

And yes the melted butter does work - I've used it with my girl, something to keep in mind

[faranya]

Back again! Ate very well this morning and drank what I'd consider a moderate amount from my water-lily bowls outside (all the cats head for those) and also the river at the edge of the lawn. He cried because he couldn't seem to find a good footing on the bank, though. Didn't appear to have vomited anything. He is outside now, resting in the shade while my husband works on a grape arbor. He likes to lounge under the vines.

But the biggest news (even though it sounds gross) is that he just had the first BM since last Friday and it was one of the longest kitty-turds I have ever seen - six inches or so! Color of liver puree. Solid but not at all dry or hard looking. No wonder the poor thing was walking around looking uncomfortable! Just the thought of all that in there makes me feel ill. I think this may be a good sign though. Means he actually did get some of the food I've been giving him.

I didn't give him his Pediapred this morning. I'm kind of scared to, having read the threads about it. It's a tough balance between "live vet" input and Net research. I'll wait a couple more hours and see how he does. He had his Clavamox, saline, potassium and diltiazem.

G's heart rate has been running around 160-180 anyhow, but the 200+ threw me a bit. Maybe he was super-stressed. He did feel really sick that day. It's terribly hard to take a pulse because he won't stop purring.

I wonder of denamarin would be useful or if it's too late for that? I can only get it from the US, though. It won't reach me for some days. I'll check out the Eukanuba. It isn't easy to find that brand here, though.

Growler, Sugarcatmom, you're the angels I've been asking for.

Brenda

[growler~GateKeeper]

Originally Posted by faranya

G's heart rate has been running around 160-180 anyhow, but the 200+ threw me a bit. Maybe he was super-stressed. He did feel really sick that day. It's terribly hard to take a pulse because he won't stop purring.

I wonder of denamarin would be useful or if it's too late for that? I can only get it from the US, though. It won't reach me for some days. I'll check out the Eukanuba. It isn't easy to find that brand here, though.

Growler, Sugarcatmom, you're the angels I've been asking for.

Brenda

As long as the heart rate doesn't spike like that again while at home under normal conditions, I'd think it probably was stress

I think the Denamarin would still be good as a supportive supplement, its not too late, it will give Gollum support to help the liver recover.

glad to help where I can

[faranya]

Thanks, Growler. The denamarin is still in transit somewhere - left Florida last Wednesday, bound for Canada. Don't know where the heck it is now.

I bought some liquid milk thistle (Hubaton/Naka) at the natural food store this afternoon to use in the interim. The label says it is prepared in a base of sea buckthorn berry pulp, fructose, potassium sorbate and Vitamin C. It doesn't mention alcohol so I have to assume there is none; I should think they'd have to include it in the list otherwise. 1 tablespoon contains 870 mg of extract preparation (mariendistel). I gave Gollum 1.5 ml; the human dosage is 15 ml, three times a day. Do you have an experience with this?

Kitty is eating, albeit peckishly, and now and then he has a little BM to prove he did get some solid food in there. He's even deigned to nibble a bit of dry food. The vet wants to keep him on the clavamox, pediapred, saline and potassium indefinitely (and of course, the diltiazem cream). I have a whole mini-cat-pharmacy on my side counter now.


Brenda

[growler~GateKeeper]

I've never used the milk thistle, but I think Sugarcatmom might have , you can always pm her to ask incase she missed your update

Good to hear Gollum is eating on his own, anything you can do to encourage him to have more is good

[Hazmat]

you mentioned "water-lily bowls outside "

Correct me if I am wrong but are not all lilies deadly poisonous to cats?

Is your cat being accidentally poisoned?

[faranya]

Thanks for the suggestion. I had thought of this myself, so I did further research because I've never known these plants to be a problem for animals. Most creatures drink from ponds in the wild and most ponds (at least locally) have water lilies floating on them. The roots are eaten by several species, such as muskrats and moose.

I found that they are not toxic to cats or dogs. Water lilies aren't true lilies (lilium) at all; they are aquatic nymphaea species from a totally different family. I keep a few tropical bloomers in bowls as they need to be moved indoors for the cooler nights. They're out in the ponds for the summer, now. Most water gardeners with pets report that their dogs or cats drink from their ponds without harm (except maybe to the pond plants if the dogs are rambunctious).

So these are not included on the poisonous-plant lists. I suppose anything can be nasty if eaten, but cats don't care for them anyhow. My cats all drink from the ponds and river, where water lilies are also plentiful. They have never had a problem with this.

Here's the Cat Fanciers list of cat-toxic plants but nymphaea/water lilies aren't on it. http://www.cfainc.org/articles/plants.html

Brenda