Exocrine Pancreatic Insufficiency (EPI)
By Rosie Raddatz
The pancreas has many functions. It produces not only insulin, but also various enzymes that provide for the digestion of food. Exocrine Pancreatic Insufficiency (EPI), commonly referred to as pancreatic insufficiency, is a condition that develops when your kitty’s pancreas no longer produces the digestive enzymes necessary to break down starches, fats and proteins which cannot get into the bloodstream to supply nourishment to the body’s tissues. Pancreatic enzymes include amylase, which break down starches, lipase, which breaks down fats and trypsin and chymotrypsin, which break down proteins. If left untreated, a cat with EPI will literally starve to death despite how much food is consumed because the food passes though the system undigested. The most common cause for pancreatic insufficiency in cats is chronic inflammation of the pancreas. Cats with EPI may also have IBD, pancreatitis and/or diabetes or could develop any or all these conditions at a later date. Symptoms of EPI are not specific to any one thing. The kitty may or may not have a ravenous appetite, vomit, or it may get to a point where it doesn’t want to eat; kitty may have foul smelling yellow diarrhea or dry, chalky, crumbly stool and will lose weight, gradually or rather quickly. The fur may look unkept.
History of my Four Cats with EPI
The following information is based on my personal experience, now having a fourth kitty with EPI in the last ten years. This information does not take the place of examinations and tests performed by your veterinarian. It is strictly an educational piece to give you some information derived from first hand experience in the diagnosis and treatment of my pets. Symptoms, tests and treatment will be explained below in detail to alert you in advance should you question certain symptoms your cat may exhibit and help you develop a plan for various testing and treatment. Links and various attachments are provided to assist you in learning more about this life threatening condition. I have also highlighted conditions of my four cats individually that have/have had this condition to alert you to symptoms as they vary from cat to cat. Some of the older articles in the links provided state that the kitty will lose weight, have a ravenous appetite and have diarrhea. While that may be true, as stated above and may be better stated in newer articles, a cat with EPI may have gradual or sudden loss of weight, ravenous or decreased appetite, diarrhea which may be yellow in color (very foul odor) and using the box numerous times during the day. Or their stool may be dry and chalky (grayish or light colored), when diarrhea is not present. They may also vomit and their fur may also look unkempt, as they’re unable to absorb the necessary nutrients.
Generally these conditions come on slowly over a period of years, or they may come and go, so we are not aware of the serious changes taking place. As the cat’s condition deteriorates, they may become very ill and may not respond to treatment. At some point things may occur rather quickly as the disease progresses. If your cat is experiencing any of the above conditions, it is critical to schedule a vet visit as soon as possible. In the past, and even now, some vets may think the kitty does not have this condition and having some knowledge of it will help you as you pursue necessary testing. Posting in an online support group before a vet visit, if time permits, will allow you to share your cat’s condition and share information with many knowledgeable people who may have a kitty with this condition or have knowledge of it.
I have had vets tell me that my cat didn’t have EPI since he didn’t have diarrhea…not true…or that he didn’t have it because they are diabetic first…not true. Having a good rapport with your vet who is knowledgeable is a necessity. At times I have had to insist on the test for EPI. I expect my vet to be knowledgeable about the condition and that it indeed does exist but to also listen to my input regarding since I live with the kitty and am aware firsthand of their symptoms. First tests should be an exam and blood work to include the full panel, CBC and T4 (rule out hyperthyroidism). If your cat has EPI these tests will generally all be in normal range. If your vet is not familiar with or still is of the assumption that EPI is rare, he/she may simply tell you “everything is fine”, a statement I heard much too often…everything was not fine. Reviewing the links provided at the end of this article before a vet visit, will give you some basic knowledge regarding EPI. The recommended GI Panel 2 W/SPEC fPL provides explanations of each portion of the tests (for EPI, B12, folic acid and pancreatitis) and will better prepare you in determining whether your cat may suffer from EPI. I always have the whole panel done rather than doing some of the tests separately later, which can save money and determine if there are other health issues requiring treatment along with EPI.
The TLI portion of the test will rule the condition of EPI in or out. If EPI is present, it can save your cat’s life by catching and treating the condition in the early stages. The good news is that once your cat is treated with the freeze-dried pancreatic enzymes properly administered they can have a normal life. Rarely, in my opinion, does EPI exist alone since it is felt the cause is from an inflamed pancreas; generally pain and inflammation (possible IBD and/or pancreatitis) are accompanying factors requiring a steroid, temporarily, or depending on the severity of the condition, may be required for life. Please be aware that when you schedule this test, a 12-hour fast is required. The blood is sent to Texas A&M lab and was the sole lab performing the TLI portion (for EPI) of the test for years. While I believe there are some other labs that might now be doing the test, I prefer to have it done by Texas A&M. If your cat doesn’t have EPI, you can now move forward in looking for the cause of the problem. There are numerous health issues that can cause some or all of these conditions. Included at the bottom of this page are links explaining these tests individually or as a group, and information on pancreatitis because of the involvement of the pancreas with EPI.
This shows the results of the test performed on my present kitty with EPI, Half Pint, in 2013. Note her TLI level was 0.4 with a normal range of 12-82…barely producing any pancreatic enzymes. Half Pint also has IBD and absorption issues. Once you have the results of the tests, be sure to discuss with your vet what medications besides the pancreatic enzymes might be needed. If your cat is low on B12, you can get it pretty economically. You can get it either directly through your vet or have them write you a script and get it from a local pharmacy or a reputable online pharmacy. It’s easy to give the injections at home rather than making your cat go to the vet for the injections; also a cost savings. My kitty also receives a folic acid supplement due to her absorption issue and I purchase it from my pet compounding pharmacy.
RESULTS OF HALF PINT’S GI PANEL 2 W/SPEC fPL
August 20, 2013
TLI (for EPI), Reference Range 12-82, Result 0.4
Comments for TLI (EPI):
Below 8.0, Diagnostic for EPI
8.1-11.9, Equivocal, consider repeating test in one month
100.0, Rule out: Renal Insufficiency, Pancreatitis, Emaciation
GI PANEL 2 W/SPEC fPL, Folate & Vitamin B12 (Cobalamin)
Cobalamin (B12), Reference Range 276-1425, Result 192 (L). (Consistent with distal intestinal disease, EPI, or small intestinal bacterial overgrowth. Check TLI to rule out EPI.)
Folate, Reference Range 8.9-19.9, Result 14.5
SPEC fPL(Pancreatitis), Reference Range 0-3.5, Result .8
Comments for SPEC fPL (Pancreatitis):
0-3.5, Normal Range
3.6-5.3, fPL concentration increased. Cat may have pancreatitis. Re-evalulate in two weeks if clinical signs persist. Investigate for other diseases.
Over 5.4, Serum concentration consistent with pancreatitis. Cat most likely has pancreatitis. Investigate for risk factors and concurrent diseases (e.g. IBD, Cholangitis, Hepatic Lipidosis, Diabetes Mellitus).
Half Pint diagnosed with EPI and IBD August 2013.
If repeated tests are run and your kitty is receiving a supplement of B12 and/or folic acid, those results will reflect the results with the supplement and will not be accurate. If the results are high, discuss with your vet as to whether the amount of the supplement should be adjusted, not stopped, running the risk of low B12 and/or folic acid.
If your kitty has EPI and receiving the pancreatic enzymes, it is not necessary to repeat the TLI as the original result will be accurate even with kitty receiving the powder and will not change.) Only repeat if your kitty did not have EPI according to a prior test result and you are rechecking.
Purchasing and Administering Pancreatic Enzymes
PLEASE NOTE THAT WHEN USING PANCREATIC ENZYMES FOR EPI KITTIES, YOU MUST USE THE PANCREATIC ENZYMES WHICH ARE FREEZE DRIED FROM ANIMAL PANCREAS, NOT PLANT DIGESTIVE ENZYMES WHICH ARE GOOD FOR HEALTHY PETS OR THOSE WITH CONDITIONS OTHER THAN EPI.
Viokase is the brand name for the pancreatic enzymes. Your vet may sell it or it can be purchased on line. A 12-ounce container costs anywhere from $220 to $260! I use a generic brand (PanaKare Plus) from Allivet that has the exact number of units…Lipase 71,400, Protease 388,000 units and Amylase 460,000 units. Pancrezyme is another generic brand available from Allivet with free shipping. I use PanaKare and I get the 12-ounce container, (see site for sizes and costs). PanaKare Plus is currently $92.99 for a 12-ounce container and Pancrezyme is considerly higher in price for the same size (12 oz.) container and has the exact same number of units. http://www.allivet.com/p-2531-panakare-plus-powder.aspx
There are other brands available, some without a prescription; however, I have never used them, they have worked for some and not for others. Due to the importance of the pancreatic enzymes, while I price shop for many products due to expenses, this is one I do not look for at the cheapest cost. Please be aware that due to the fact that this is a digestive enzyme, if you get any powder in a finger cut, it will burn, it digests, that is its purpose. Just wash immediately and clean up your counter area with soap and water after use. Also be aware that your cat may not like the digestive enzymes in their food. If they eat kibble, the recommendation is to transition them to a good all wet, grain free diet (or raw food diet). Vets will generally recommend a prescription diet, which I do not use. While it may take time to transition to a better diet, there are ways to slowly do this and get the enzymes in as well. Please see the link on this site in the Food section for Switching Foods.
You will need to adjust the amount of powder you need to use; the instructions recommend a higher dose and then lower if needed. I suggest starting with a lower amount and increase as needed due to the (most likely unpleasant) taste of the powder. (I started out with 1/8 teaspoon of powder to ¼ can (5-1/2 oz. can) of food. After a few days you can increase to ¼ teaspoon of powder to ¼ can of food. You will be able to tell when you have enough generally by kitty’s stool. If they had diarrhea, you should see a change in a few days to more solid and normal color; if dry and chalky, it should start to become normal. A good baby scale is helpful also to check on weight. I only weigh once a week, some do daily. If a further change is needed in the amount of powder, I wait a week. One of my cats used 3/8 teaspoon to ¼ can of food, or a 1 oz. raw food nugget. You don’t want to overdo, but the amount may differ by each cat. My present kitty is on a raw food diet as was one other. This one uses the equivalent of ¼ teaspoon powder to a meal. (I had to capsule the powder for one cat and sit with him, “popping” capsules as he ate.) I don’t recommend this method, but it was the best way to get him to “accept” the powder and it worked. (I used a No. 2 capsule.)
The powder must be used in all foods they eats, remembering that they are not producing digestive enzymes and the powder is now giving the enzymes needed to break down the food. If you warm the food for 4 or 5 seconds that’s okay but do not use in anything too warm as it kills the enzymes. I use a mortar and pestal to grind the powder a little more in case of any granules. You can sprinkle on the food and add a tiny bit of water (1/2 teasp.) and mix it in thoroughly. Directions indicate to incubate and let the food sit for 5 or 10-20 minutes. But some research indicates it is not necessary to do this. I don’t incubate since I need to “syringe feed” a mixture with the powder. Feel fortunate if your cat eats their food with the powder in it, but there are a few tricks you can use. If your cat likes a food topper, you can sprinkle a little on top. If this doesn’t appeal to them there are other ways to disguise the taste and smell of the pancreatic enzymes. To “disguise” the taste of the powder I suggest purchasing a sugar free syrup (SyrSpend SF) and (Natural Bitterness Masking Powder) mixing separately a “dab” of food, about 4-6 drops of the syrup and a little of the bitterness masking powder (I use the small “drop” spoonful).
I also use a flavored powder called Medisca. I use the tuna flavor and mix 1/2 tsp. of powder to ½ cup of water. Use a small amount of this flavored liquid, ½-1 tsp. or you can use a small amount of water or bone broth. (Do not use canned soup broth or anything with sodium). The main thing is to disguise the taste with the masking powder and sugar free syrup. You can store the remainder for several days in the fridge. The compounding pharmacy I use for my pet medications orders the syrup, flavored powder and the bitterness masking powder for me, a prescription is not needed. It lasts a long time and they ship ground free. This is what is used by pharmacies to disguise the bad taste of medicine. http://www.universalcompounders.com/
If your cat still won’t eat the food with the mixture, you can make up what I call the “gruel” and syringe feed. I use about ½ tsp. of food, drop spoon (rounded) of the bitterness masking powder, 4-6 drops of the sugar free syrup and about a teaspoonful of liquid, (flavored water mixture, water or bone broth) and the amount of pancreatic enzyme powder you need for your cat. If you are giving your kitty supplements most of them can be added to this mixture also (I add my cat’s probiotics, Canna Companion and immune support supplement). I use the Four Paws Pet Easy Feeder from Amazon. I slowly syringe the “gruel” mixture immediately after every meal in order for it to work with the food eaten. Instructions say to give before food, but I can’t do that as it would “spoil my cat’s appetite”; however, it must be done immediately after eating to properly create the digestion process of the enzymes. I also syringe a small amount of water afterward in case there is an “after taste”. If you notice any redness around your cat’s mouth in the beginning, (per my vet) you can use a tiny bit of Neosporin. (It took a few syringes to do this properly!)
I DO NOT RECOMMEND MIXING THE ENYMES WITH WATER ONLY AND SYRINGING. THIS CAN CAUSE EROSION OF THE ESOPHOGUS OVER TIME DUE TO THE HARSHNESS OF THE ENZYMES.
If you have a multi-cat household, the other cats should not have access to any of the food with enzymes in it. I suggest feeding your cat separately. Also, you will need to decide how to be sure your cat gets their food if you are gone for the day, and you need to make sure they don’t have access to food without the pancreatic enzymes. This may require keeping your cats separated. You can also use a timed feeder while you are gone. These are things you will learn to work out according to your schedule. I use a feeder that has an ice “block” to keep the enzymes active and can leave two feedings. If your cat is hesitant about eating the food with the powder, you may not want to put more than 1/8 teaspoon mixed with the masking powder, etc. in each tray. You’ll also want to time the first feeding 3 hours after “breakfast” and the second side three hours after the first side. My cat will eat the food if necessary in the feeder if I am gone. The ice block keeps the enzymes active 6-8 hours. Amount of powder to amount of food can always be adjusted. If you free feed your cats, you might want to consider timed feedings.
Once your cat is getting the proper amount of enzymes in the food, they should gain some, if not all of the weight lost. Do not be discouraged as it may take time for everything to “fall” into place.
Past (Nutmeg, Puck and Jazzy) and Present (Half Pint) History of my cats with EPI:
Nutmeg: EPI is a condition very close to me due to the fact that I lost my first EPI kitty in 2006, not knowing what was wrong until it was too late to save her. Nutmeg was a part Manx cat and became a diabetic just under 12 years of age. Her diabetes was well controlled until sometime during her 16th year. She started having diarrhea several times a day and lost weight. During her vet visits her weight loss was attributed to muscle loss with no explanation for her diarrhea. Nutmeg went from a plump (not fat) kitty of 11 lbs. to 6 lbs. over several months. My research had not given me the right answers as she continued to lose weight. Her insulin requirements changed, her appetite diminished, her electrolytes became low requiring her to go on an IV to bring them in the normal range. Somewhere in her last month I was given pancreatic enzymes to try, she hated them in her food, I didn’t know how to properly administer them and I tried raw pancreas. She contracted a respiratory condition and it broke my heart. I let her go, while she was still loving, in spite of her vomiting and continued decline. I’m sure she would not have lived more than a few weeks and I knew I couldn’t save her; I wanted to remember her feeling well. Her pictures are posted from her healthy time and her declining condition. These photos are posted to show how a cat can be affected when the pancreas isn’t producing the digestive enzymes needed and the extreme weight loss of a cat that continued to eat but could not absorb her nutrients.
Puck (diagnosed with IBD in 2009) began vomiting up loose hair almost daily; I told my vet it was as though he was growing hair in his stomach. Routine blood work was normal, x-rays and ultrasound revealed nothing unusual; he had lost about 1-1/2 lbs. He was diagnosed with severe IBD by an endoscopy and put on a novel protein diet (Royal Canin rabbit or venison by the vet that did the endoscopy, a diet that had grains in it) and budesonide. This seemed to help but he still had periodic vomiting of bile and after a year he had lost a pound of the weight he gained back. Again, blood work and an ultrasound showed nothing. I took the advice of a friend and put him on a raw food diet. Within a few months he had gained his weight back, no vomiting and, of course, the vet I then saw did not approve of a raw food diet asking if I was attributing his weight gain to his diet to which I responded “You bet I am!” This was about the time I moved (2010) and in 2012 at his annual exam he had normal blood work, weight 12-1/2 lbs. It was determined he needed to lose a little weight. I reduced his food intake slightly and six months later he looked like he lost more than I had wanted him to. He showed no signs of illness; he was fed separately and by the time I got to the door his plate was empty. He had lost 3 pounds in 6 months! All his blood work was normal. I mentioned EPI since I was now familiar with the symptoms. My vet said he didn’t have it since he didn’t have diarrhea and I responded that I knew he didn’t need to have diarrhea. She also said they usually were diabetic before they got EPI. I insisted on the test. His TLI test revealed 0.3 (normal 12-82). Puck did very well. We had somewhat of an adjustment period but he did accept the pancreatic enzymes in his food with a little doctoring. He remained on 1 mg. budesonide. I knew in May of 2014 he was in the “winter” of his life. We made a few adjustments, which gave us 2-1/2 more months of quality life, and he lost his battle July 18, 2014. From the time he was diagnosed with EPI he gained 1 pound back, he was at a good weight. His life with IBD and EPI was clearly filled with good health and love, with continual learning on my part on how to manage what I consider these dreadful diseases.
Jazzy was diagnosed with IBD and pancreatitis by the GI Panel 2 W/SPEC fPL in April of 2012. Over the prior years he had periodic bouts of very stinky diarrhea and vomiting which cleared up within a day or two. Since it cleared up quickly and his symptoms were different than two other kitties, I did not know he was now suffering from IBD. He did not have EPI at that time but had pancreatitis when diagnosed and IBD. He was a very sick kitty. Jazzy had originally been a heavy kitty but a diet of gradual weight loss had him at around 16 lbs. from the 22 lbs. when I adopted him. He looked good at 16 lbs.; he was a large kitty. When he was diagnosed with IBD and pancreatitis he weighed a little over 14 lbs. He was first put on prednisolone with no help regarding his diarrhea and shortly thereafter was put on budesonide and some supplements. He would not eat a raw food diet and remained on a good grain free canned. He had gained a little of his weight back and then gradually started to lose some. Late in 2011 he was diagnosed with EPI. He wouldn’t eat the powder in his food, I had to act quickly because of his condition and I measured the amount of powder needed and capsuled it. This worked fine for Jazzy as I was able to “pop” his capsules in as he ate. He was periodically vomiting up liquid in his last months. He was down to slightly over 12 lbs., not scrawny, but way too thin for a cat of his size. In late August of 2014 he had put on about 2 ounces and I was delighted, finally the powder was working…I thought! However, a few days later he weighed a few more ounces and my heart sank. I presumed he had cancer and was retaining fluids. I had an appointment for him and realized the night before we would need to say good-bye. He vomited tons of liquid and while he still wanted to eat; I could not take chances with bad things happening to him. I had a kitty in past years with intestinal carcinomatosis that retained fluids and I was able to maintain her with treatment for 18 months. However, Jazzy’s condition was very different from hers…I don’t know if that was the kind of cancer he had. I said goodbye to my big angel on September 17, 2014, just one day less than two months after Puck transitioned to the Rainbow Bridge. Jazzy was 16 years, 4 months.
Half Pint (My present kitty with EPI). Half Pint came from a feral environment along with her three brothers, one of whom was adopted. As kittens they ate some canned food and by the time they were under a year old would only eat a very small amount of canned and became dry food junkies. Now I realize their issues began when they were very young; occasional vomiting, excessive grooming, many vet visits; diagnosed with food allergies, seasonal allergies; etc., etc. Allergy testing for one revealed no allergic reactions. Through the years some were put on prescription diets, limited ingredient diets, and various changes. Vomiting became more prevalent even though Half Pint didn’t act ill. There was weight loss. Vomiting now was becoming almost daily. In July of 2013 her brother, Koal, was diagnosed with IBD and pancreatitis. In August of 2013 Half Pint was tested, I thought her condition would be the same as her brother’s. Half Pint was diagnosed with IBD and EPI. (Her test results are the ones posted earlier in this article. I almost lost it. She was a dry food junkie, a grazer. I tried to moisten the food and coat it with powder (I don’t recommend this.) No deal. I gradually tried to get her to eat a little canned. I purchased the masking powder, syrup and flavoring powder from my pet compounding pharmacy. She wouldn’t eat the mixture in her food. I tried syringing somewhat different than I do now; I syringed too much water afterward and she vomited. I was sure I would lose her; all I could see before me was the skeletal figure of my precious Nutmeg from years ago. I succumbed to making up capsules with the powder as I knew that was an option (one I don’t like and would only do as a last resort). Finally got her off the kibble, she didn’t like canned that much and I slowly transitioned her to raw. She continues to be a grazer and a picky eater. She was put on budesonide and it did not affect her with a “hunger” as her brothers. She had lost about l-1/2 pounds and a year later had regained about one pound. After some issues, I didn’t like the procedure of capsuling the powder and went back to making up what I call the “gruel” and syringing after talking with someone who syringed. I recouped the masking ingredients from the cupboard and went to that system which is how she gets it today which works very well. Half Pint’s EPI is well controlled two years later while she does have some other health concerns. She is the love of my life.
Articles re EPI in Cats and Tests for EPI, B12, folate and pancreatitis
GI Panel 2 W/SPEC fPL (for EPI, B12, folate and pancreatitis) (Recommended)
TLI test for EPI only in cats
Test for EPI (TLI), folate and B12 in Cats