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Frequently Asked Questions About Leukeran (chlorambucil)
By Rebecca Kimsey

1) What is Leukeran? Leukeran is the brand name for (generic) chlorambucil. It is an immune system suppressing drug given to dogs or cats for immune-mediated disorders such as cancer, including leukemia and lymphoma. It is also used as a treatment for severe non-responsive Inflammatory Bowel Disease (IBD). Note: in this FAQ the term Leukeran is used, but except where noted, the discussion applies equally to chlorambucil.

2) Why give Leukeran? If your kitty has been diagnosed with small-cell lymphoma, Leukeran is a proven, effective treatment that is very well tolerated by cats. It can put your cat into remission from this cancer. It is also prescribed for severe non-responsive IBD as an immune system suppressant with strong anti-inflammatory properties. https://www.ibdkitties.net/ibd-or-cancer/

3) Leukeran is a chemotherapy drug. It sounds dangerous, is it? Any medication has risks. It is true that Leukeran is a powerful drug, but careful handling as discussed below, and washing your hands are the usual precautions.

4) How is Leukeran given? It is an oral medication. It is a brown tablet (Leukeran), or compounded into pills, capsules or liquid medication as chlorambucil.

5) What is difference between Leukeran and chlorambucil? Which should I give? The brand name of the medicine is Leukeran; it’s a small brown 2mg tablet. The company that manufactures Leukeran does not produce the generic. This is why the generic, chlorambucil, is a compounded drug. Legally, compounding pharmacies may not produce a 2mg dose. This is why chlorambucil may be in doses of 1.9mg or 2.1mg, and may be compounded as a tablet, capsule or oral medication.

6) Does it only come in pill form? Leukeran is only available in 2mg brown tablets. The compounded chlorambucil can be made as pills, capsules or liquid.

7) How much does Leukeran cost? In the U.S., Leukeran is very expensive, at about $26 to $28 per pill. The compounded generic is more reasonably priced; many use chlorambucil instead of Leukeran because of the cost. Leukeran in other countries (such as Canada) has run about the same price as chlorambucil in the U.S. Some vets will insist on the brand drug (Leukeran) due to concerns about compounding inadequacies, but we are not aware of any reported problems with the compounded form.

8) What about my other pets? Just keep the litter box clean, and if you have a dog, do make sure they don’t eat the poop. That’s all that’s needed. Cats can groom each other, you, etc. No special precautions other than perhaps scooping more than you normally do. The usual recommendation is 2x a day. As people with IBD cats, we assume that all of us scoop at least that often.

9) Do I have to take special precautions? Generally wearing gloves when giving the dose, and regular, thorough hygiene and hand washing are adequate and the normal precautions. Some vets warn against touching urine, feces, saliva; others don’t even tell you to wear gloves when giving the dose. But who among us gets poop or urine on our hands and doesn’t wash up right away? Of course, if you are immune compromised yourself, you may need to take extra precautions. Please discuss with your vet.

10) What dose of Leukeran should I give my cat, and how often? Your vet will determine the dose and the frequency of delivery. The most typical dosage has been 2mg every other day. There are variations in frequency including every second or third day, to a much higher dose (approximately 6mg) given approximately twice a month (which works out to a lower overall dose). Some cats are started on the more frequent dose, then switched to the twice a month dose.

11) How long will I give Leukeran? Your vet will advise you. Kitties in the IBDKitties support group have been on the medication for a year or longer. When used for small cell intestinal lymphoma, some cats are put on it for life; some oncologists prescribe it only until kitty is determined to be in remission. When used for severe IBD, it ranges from short to long term, depending on your cat’s response and need.

12) What can I expect when my kitty first starts taking Leukeran? What are the side-effects and will my kitty have the same kind of problems that humans on chemotherapy do, such as hair loss, nausea, lack of appetite? Leukeran is usually very well tolerated. Only about 15% of cats experience side-effects that result in discontinuing its use. As with all chemotherapy in cats, the approach is focused on quality of life, and thus dosages are much lower than human equivalents, minimizing potential side-effects. The experiences of pets on chemotherapy cannot be compared to experiences of humans for this reason. The most common side effects can be lethargy, lack of appetite, nausea or vomiting; diarrhea is possible, though often diarrhea is already present prior to treatment. These symptoms may occur at the start of treatment, and ease over time. And of course, some of the symptoms are the same we face with IBD or pancreatitis. Your cat will need to be monitored for the drug’s impact on bone marrow, as bone marrow suppression is possible. This can result in anemia, or depressed white blood count, or changes to other blood enzymes. If this happens, the treatment is stopped until the bone marrow responds, usually within a few weeks at most, and then kitty can resume the treatment.

13) What can help with the side effects? Just as in IBD or other gastro-intestinal issues with our kitties, anti-emetics, anti-nausea, anti-acids, and appetite stimulants can be essential tools in combating vomiting or lack of appetite. Canna Companion has helped some kitties as well.

14) I’ve heard that it’s necessary to regularly do blood tests when cats are on Leukeran. Why? As mentioned, one of the possible side-effects of the chemotherapy is bone marrow suppression. This can lead to anemia, and that can be fatal if not monitored and managed. Thus, it is necessary to do regular CBC (Complete Blood Count) testing to measure any change to Red Blood Cells, White Blood Cells and Hematocrit (RBC, WBC, HCT). A sudden, lasting drop in the HCT will mean that Leukeran will be stopped, at least temporarily. Your vet should advise a regular schedule to do the CBC. It may range from weekly or bi-weekly in the beginning, to monthly, or some similar schedule. If your vet does not tell you, be sure to discuss the need for regular and on-going monitoring.

15) Is Leukeran all the medicine that my kitty will need to take? If not, what others are given? A steroid such as prednisolone is usually prescribed in conjunction with Leukeran, and often at a higher dose than normally prescribed for IBD. Other steroids can be used. A possible regimen might be 2mg Leukeran every other day with 10mg prednisolone daily. The purpose of this is to aid in immune system suppression and combat inflammation associated with bowel disease, or cancer. Your vet should discuss with you the drugs used to combat the IBD or lymphoma, as well as any other supportive meds. These might include those for nausea, vomiting, inappetence – which we are familiar with from IBD or pancreatitis. https://www.ibdkitties.net/introduction-to-steroids-4/

16) Does Leukeran cure lymphoma or severe IBD? Leukeran does not cure IBD. The practical experience with use of Leukeran in the treatment of small cell intestinal lymphoma diagnosed via biopsy is that 85% of the time, Leukeran puts kitty into remission.

17) Is special handling necessary? Leukeran MUST be kept refrigerated. It cannot be cut or crushed. Avoid contact with the medication. Wear gloves when administering the dose.

18) Do you have to have a biopsy diagnosis in order to start Leukeran? In our experience, this will vary. A vet who isn’t familiar with your kitty is far more likely to insist on a biopsy. If the vet has been treating your kitty for considerable time and is therefore more familiar with kitty’s history, especially if there have been previous ultrasounds or biopsies, they should be more willing to start Leukeran without a confirming biopsy. Some vets will not give the drug, perhaps for legal reasons in some states, and will instead refer you to an oncologist or internal medicine specialist for treatment. These new doctors may or may not want a biopsy done. Be aware that if your kitty is on a steroid, she will need to be slowly tapered off the steroid for a biopsy to be worthwhile. Note that a biopsy is the best method of determining if your kitty’s bowel issues are from IBD, or from lymphoma, or other cancer. If cancer, the most common type is small-cell lymphoma, which responds very well to Leukeran, just as IBD does. If it’s large-cell lymphoma, then a completely different chemotherapy protocol is required.

19) My vet hasn’t mentioned Leukeran. What can I do? Ask the vet about using it. I suggested it to my vet for my Boston. My vet had no experience with it in cats, but did discuss with our internist, and they agreed it was time to start Leukeran. Some vets have no experience with it, particularly in cats. There are Case Studies on the IBDKitties website about cats who have been on Leukeran (see below).

20) My vet still doesn’t want to give it, but I think it may be necessary. What can I do? Discuss further as to why your vet doesn’t want to give it. If it’s due to their lack of experience with this protocol, ask if they would consult with a specialist (internist, oncologist) who does have the experience. If they won’t do that, and you do want to pursue this treatment, then consider either going to another local vet, or to a specialist. Ask for a referral for a specialist from your vet. Or ask in the group, or look at the AAVA website for specialists or vets in your area.

21) Case Studies – IBDKitties website:
https://www.ibdkitties.net/case-studies-4/zoe-o/
https://www.ibdkitties.net/case-studies-4/disco-t/
https://www.ibdkitties.net/case-studies-4/bumbly-a/
https://www.ibdkitties.net/case-studies-4/sally-p/

22) How long before I can expect to see any results? That, of course depends on what is wrong with your kitty, how severe the condition is, the overall health of your kitty, plus how well they respond to the drugs given: Leukeran, prednisolone. Many kitties on Leukeran have severe diarrhea as a symptom of their illness (whether IBD or SC lymphoma). Some kitties have seen formed stool within the first week; others have taken four to six weeks before reaching that point, although associated foul smell and/or pale color tend to improve earlier. Please note that if you are not already giving your cat b12 shots, this should also be discussed with your vet, as diarrhea often will not resolve until B12 levels return to normal. https://www.ibdkitties.net/the-importance-of-b12/

23) What if my cat can’t tolerate Leukeran, are there alternatives? Treatment with high doses of steroid alone is one option. Atopica (cyclosporine) is another. They may or may not be effective alone, or together. There may be other alternatives. Talk with your vet.

24) What if I miss a dose? As with human medication, if you miss a dose, give as soon as you realize, UNLESS it is nearly time for the next dose. Do not double up on a dose ever, as this may result in toxicity.

25) What else can I do to support my kitty while on Leukeran?
— Feed the best food you can: https://www.ibdkitties.net/feline-nutrition/
— Give probiotics to help with digestion: https://www.ibdkitties.net/probiotics/
— Ensure adequate levels of B12: https://www.ibdkitties.net/the-importance-of-b12/

By Laurie Goldstein

The Background: The Biological Needs of Cats, a metabolically inflexible hypercarnivore
Given the first records of the domestication of cats dates back to when humans were first settling down to farm (1), it’s easy to imagine both human and cat enjoying the benefits of proximity, isn’t it? They’re magical, entertaining creatures, cats are. And they protected the farmers’ grain stores from rodents. It was a win-win! We’ve been companions ever since. Cats traveled the globe with us. Literally, as it turns out.

It came as quite the surprise when a research team led by geneticist Carlos Driscoll of the National Cancer Institute and scientists at the University of Oxford in England decided to trace the origin of domestic cats – and found that every single one of the 979 cats included in the project from around the world were “virtually indistinguishable” from the African Wildcat at the genetic level. That’s right, that purring, kneading bundle of soft, silky fur, born under different circumstances, could be just as at home stalking prey on the great plains of South Africa.

Many assume the influence of living among humans would have had an impact on what cats have the ability to eat and use for sources of energy and nutrition, as appears to the be case for dogs. (2) Nope. Not so. Not at all.

Despite their proximity to humans for at least 10,000 years, cats retain their unique anatomic, physiologic, metabolic, and behavioral adaptations consistent with eating a strictly carnivorous diet. (3) That is to say that cats, to this very day, remain obligate carnivores – and not just obligate carnivores, but hypercarnivores (4). By their genetic makeup, cats must eat the tissue of other animals in order to thrive.

Our kitties delight us with their playful antics well into old age. And as we’ve brought our cats indoors full-time, we find that to keep them happy and fit, we have to engage them in interactive play. What we are witnessing is their prey drive. That seemingly kitten-like, playful behavior we enjoy from birth to death in our furry friends is unique to cats: their prey drive is not dependent on hunger. (5) They are so hard-wired to hunt and engage prey, they don’t need to be hungry to hunt – to “play.”

In short, everything about the cat is defined by its role as an apex hunter. Cats are literally “designed” to eat a strictly carnivorous diet. Some examples:

⦁  Cats are hypercarnivores. As a hypercarnivore, cats have a higher protein requirement than even most other carnivores. (6)

⦁  Cats cannot downregulate protein metabolism. If they do not get enough meat-based protein – the only source of protein that provides them with all of the amino acids they need – they rob their own muscles for it. (7)

⦁  Cats must have preformed arginine and taurine. A lack of these in the diet rapidly causes blindness and death: only animal protein provides these at levels cats require. (8)

⦁  Cats must have preformed omega 3s (EPA and DHA). Cats lack the digestive enzymes necessary to derive anti-inflammatory benefit from plant-based omega 3s. (9) Flax seed is a current popular addition to cat foods – it is marketed to humans as being one of the plant sources highest in omega 3s, yet cats are unable to access the EPA (eicosapentaenoic acid)  and DHA (docosahexaenoic acid) within it. The omega 3 in plants is in the form of ALA (alpha-linoleic acid), which humans break down into its anti-inflammatory components. Cats do not possess the digestive enzymes required to make this conversion. According to Dr. Jean Hofve, “while ALA has beneficial effects of its own (particularly on skin and coat health)… [and] even though ALA is technically a precursor of EPA and DHA, dogs and especially cats have an extremely limited capacity for converting it (no more than 1% to 2% for EPA and virtually 0% for DHA after weaning). Only marine-sourced oils (fish oil, krill oil, green-lipped mussel oil, and some algae oils) contain the pre-formed EPA and DHA that our carnivorous animals can absorb and utilize. Cats and dogs must receive EPA and DHA directly.” (10) To derive the anti-inflammatory benefits from omega 3s, cats must have them preformed – available only from animal tissue. Many people wonder – where did desert cats get omega 3s? Naturally occurring in their prey. It is our farmed animals that have lower omega 3s than their natural prey. We also do not feed the parts of animals that contain the most omega 3s: neural tissues (brains, eyes, and spinal cord). (11)

⦁ Cats must have preformed arachidonic acid, an essential fatty acid not found in plants. This is for the same reason as the requirement for preformed omega 3 fatty acids. Cats have a special need for the omega-6 fatty acid, arachidonic acid (AA), one of the two essential fatty acids in the cat’s diet. Many mammals, like dogs and people, can synthesize AA from linoleic acid (LA). Cats cannot make the conversion due to the absence of delta-6 desaturase activity. AA is abundant in animal tissues, particularly organ meats. Plants do not contain AA. (12)

⦁ Cats must have preformed vitamin A from animal tissue. Cats also lack the digestive enzymes necessary to derive benefit from plant-based sources of vitamin A. (13) Vitamin A comes from two sources: retinoids (animal-based) and carotenoids (plant-based). Retinol is preformed vitamin A, only available in animal-based sources (e.g. liver is rich in vitamin A). Cats cannot access the vitamin A from common ingredients we see in cat foods such carrots, pumpkin, sweet potato, spinach, and kale. If there is no liver in the cat food, synthetic vitamin A is added.

⦁ Cats must have preformed vitamin D. Cats do not synthesize vitamin D from sunlight, (14) and their bodies use vitamin D from animal tissues (cholecalciferol) much more efficiently (13) than plant-based vitamin D (ergocalciferol).

⦁ Cats appear to have a carb threshold. (15) beyond which they do not derive energy benefit given their high need for protein.

⦁ Energy from carbohydrates cannot replace needed energy from protein. (16) Many cats overeat on a high carbohydrate diet. They eat more calories than they need to maintain a healthy weight because they are trying to access enough protein.

⦁ The sugar transporter in cats’ intestines is nonadaptive to changes in dietary carbohydrate levels. (17) This literally means that anything other than a low-carbohydrate diet stresses their entire GI systems.

⦁ Salivary amylase, the enzyme used to initiate digestion of dietary starches (carbohydrates) is absent in cats, (18) and intestinal amylase appears to be exclusively derived from the pancreas. In fact, cats have just one pathway for digesting carbohydrates (compared to dogs and people, who have multiple pathways). Of course, these enzymes are not necessary in a prey-based diet with minimal starch content.

⦁ The level of pancreatic amylase is only 5% that of dogs. (19)

The evolutionary history of the cat indicates that it has eaten a purely carnivorous diet throughout its entire development. It is critical to their long term health that we understand cats are a nutritionally and metabolically inflexible carnivore. This is even more important for cats with IBD. They need food they can best digest and utilize and that supports their proper GI pH to restore colonies of healthy bacteria.

Where Things Stand: Current State of Cats’ Health
Since moving indoors full-time and becoming completely dependent on us for food, what has happened? We need convenient food with our busy lifestyles. And most of us do not intuitively understand what cats need – they seem like little aliens to us. They certainly did to me. So we ask our vets. And many of our vets tell us that for dental health, cats need kibble, that to mimic their “natural” pattern of eating many small meals (being hunters of small mammals), we should leave the food out. We didn’t know any better, and we trusted our vet to know what’s best for Bella. Or we free-feed kibble to our kitties, because that’s what and how our parents fed our cats when we were growing up, and those kitties lived long, healthy lives. So 80% of us (20) go to the store and buy a bag of kibble, come home, and pour it into a dish we keep full for Boots, and Socks, and Tigger. And yet we keep Boots and Socks and Tigger indoors exclusively, where our childhood friends were usually indoor-outdoor cats, supplementing their dry diet with healthy, freshly hunted prey. (If your kitty brought you gifts, that most certainly meant he was eating them, as research indicates that kitty only returns one in four hunted animals to present as gifts to his family. (21))

 …except cats evolved eating moisture-rich food in the desert. (22) Kibble has virtually no moisture – and cats do not have a thirst-drive that keeps them properly hydrated (23). This is a clash of momentous impact: The number one reason for a vet visit by cats is bladder or urinary tract problems (24) – usually crystals and life-taking or life-threatening urinary tract blockages –problems that need not exist if we feed a moisture-rich, meat-based diet. (25) Cats, not designed to use all those carbs, grains, or starches in their food, not designed to derive needed protein from non-meat-based sources, and requiring moisture FROM their food to remain properly hydrated, experience kidney disease at a rate of seven times more than dogs (26).

And our kibble fed cats, chronically dehydrated, die most frequently from kidney disease, the number one cause of death in cats over the age of five (27). Yet in the face of this, many of our vets STILL tell us our cats need to eat some kibble for dental health. And despite the fact that 80% of people with cats feed dry food, 85% of cats over the age of three years have dental disease (28). What the…. ????? How can they not notice this dichotomy?

So we put down that bowl of kibble for kitty to “graze.” Except cats aren’t herbivores. Cats shouldn’t graze. Allowing cats to graze has resulted in a problem of “epidemic proportions.” 58% of our cats are either overweight or obese (29) – an increase of 90% over the past five years (30). So now we have fat cats. And that means 67% of our cats have arthritis (31). And being fat increases the risk of diabetes by 300% – 500% (32) – so it shouldn’t be surprising that the incidence of diabetes in our cats has DOUBLED in the past five years (33).

As to Inflammatory Bowel Disease? THREE of the top 10 reasons for vet visits by cats in the past several years are related to digestion. Our cats suffer chronic vomiting, diarrhea, and now? Now full-blown Inflammatory Bowel Disease (IBD) makes the “Top 10” list for vet visits (34). Is it any wonder, really, once we understand what they naturally eat compared to what so many of us feed them?

The Nutritional Profile of the Cat’s Natural Diet
Wait – Don’t Cats Eat ANY Grains, Grasses, or Vegetables?
No. Not naturally, no they don’t. Some cats love to chomp grass, eat lettuce, or have a bread obsession. I love donuts – this does not mean it is a good food choice for me. In their natural environment, they don’t have access to much but grasses. And those? Well, the studies indicate grass eating is rare: ingested grass is likely incidental while bug hunting. Cats are not natural to many environments, and their impact on those environments is hotly debated, thus there are many feral cat predation studies – which are the same thing as feral domestic cat diet studies. Thanks to those studies, we have a VERY clear picture of what our domestic cats eat in the wild due to the efforts of Dr. Esther Plantinga and colleagues, who analyzed that data. We now know exactly what the average nutritional make-up of that diet is. In a meta-study published in the British Journal of Nutrition in 2011, Estimation of the dietary nutrient profile of free-roaming feral cats: possible implications for nutrition of domestic cats, the entire body of feral cat diet studies (of which there is a very large body) was parsed to eliminate studies of Wildcat diets; all studies with a small number of cats; and all studies where cats had access to more than 5% human provided food (even if garbage). (35) This yielded 27 studies. Analysis of those studies found the natural diet of a domestic feral cat, on average, is (on a dry matter basis).

62.7% protein
22.8% fat
11.8% minerals
2.8% carbohydrates

The amount of carbohydrates cats naturally eat is very, very small. Where does it come from? 21 of 27 studies reported small amounts of plant material found in the diet. One of the studies reported that 26% of the cats consumed vegetation consisting mostly of a few strands of grass. The authors concluded that plant material is a minor component of the diet of feral cats, and that ingestion is likely to occur “incidentally while foraging for invertebrates.” So for the most part, carbohydrates from plant matter are not a meaningful or even intentional part of the diet. In fact, those carbs come from what their prey has eaten: “…when consuming whole prey, as cats naturally do, the digesta [stomach contents and nutrients in the intestines] of prey items may contain some starch.” The authors note that the digesta mass of mice and rats is a very small component of the cats’ diet, being just 0.5% – 2% of the body weight of the prey.

So cats do not naturally – intentionally – eat carbohydrates. The study authors indicate “Almost all of the metabolic adaptations related to the carbohydrate content of the diet indicate the lack of this nutrient in the evolutionary diet. It could be argued that the shift from an obligatory meat-based natural diet to a meat-and-grain-based pet food rich in carbohydrates may place the cat’s metabolism under stress, and might have unwanted negative health effects in the long run.”

While cats vary exactly what prey they hunt based on where they are, one thing does not deviate: they consume small animals. The summary of what they eat was provided:

⦁ Mammals – 78% (Most often rabbits and rats, though there is a large variation between studies based on location)
⦁ Birds – 16%
⦁ Reptiles/amphibians – 3.7%
⦁ Invertebrates – 1.2%
⦁ Fish – 0.3% of items consumed. Fish-eating was present in just 3 of the 27 studies.

Cats eat small prey mammals. Not grains. Not legumes. Not vegetables. Not fruit. Essentially no fish – not even much “poultry” (birds). So why, then, do so many cat foods contain fish, soy, corn, wheat, rice, peas, spinach, kale, blueberries, cranberries – tomato? What are we doing to our cats? How has this happened?

The Problem: Pet Food is Marketed to Humans
If cats were in charge of the pet food industry, cat food instructions would read, “remove mouse or rabbit from freezer: thaw and serve.” But feeding cats what they were meant to eat is not how the industry developed. The first commercial pet food was offered for sale early in the 20th century. It began as an offhand utilization of what was basically considered “meat junk,” the garbage created from human food production. …except very little was known about the actual nutritional needs of dogs and cats. Most fed table scraps, and cats were allowed outdoors to hunt. And then World War II happened. With food rationing, we could not afford to feed our pets meat and what was considered “food waste” changed. Mark Morris, founder of Hill’s Pet, was the first to focus on the role of diet in pet health, focusing on research to determine their nutritional needs – and helped avert a mass euthanization of dogs by formulating a grain-based food. (36) And thus the species-inappropriate diet was born. It served its purpose. But the low-cost benefit remained, and as more and more people brought pets into their lives and homes, a new field of pet food “science” emerged with the goal of formulating nutritionally adequate food with cheap ingredients that have marketing appeal to people.

Today, multinational cat food companies have a global reach and invest a great deal of money and time in research and development to “build” cat food from ever-cheaper nutrient components, using chemicals to make them as tasty as possible (37)  – all with the goal of minimizing costs and maximizing profits. As technology has progressed, more and more of the “waste” from human food production goes back into human foods, leaving true waste products, downed animals and roadkill for pet foods. (38, 39, 40). There are many companies that enter the market seeking to provide “higher quality” foods that are made from organic ingredients, or perhaps ingredients that are more appropriate for an obligate carnivore, responding to growing consumer awareness of what our cats (and dogs) actually need.  But this spectrum results in a great variety of cat food – all of which is marketed as optimal nutrition, leaving consumers confused, and turning to their vets for information.

Yet our vets receive very little nutritional training. In many Veterinary Universities in the U.S. and the U.K., the classes are often provided not by University staff, but by visiting Veterinary Nutritionists on the staff of the Mark Morris Institute. What is the Mark Morris Institute? Mark Morris founded Hill’s Pet Nutrition, and his son endowed the Institute in his father’s honor, in keeping with the company’s marketing strategy of using the vets to market their food. (41) The Mark Morris Institute pays a dozen veterinarians, whom they send, free of charge, to veterinary schools to teach pet nutrition:

“The Mark Morris Institute University Teaching Program in companion animal clinical nutrition offers current, non-commercial nutrition learning activities at no cost to the hosting school. Mark Morris Institute offers a series of lectures, case-based discussion, labs and video presentations which can be combined to create a customized clinical nutrition course for your institution.” (42)

Hill’s Pet provides the textbook, Small Animal Clinical Nutrition, usually free of charge to students. (43). So how can we, as consumers, expect to obtain unbiased information on the best diet to feed our pets from our veterinarians who sell the prescription foods of the company that taught them about nutrition? We certainly mean no offense to our vets, as we are sure that they recommend only what they think is best for our cats. But this is a fundamental conflict of interest. This is akin to our doctors learning about baby nutrition from Nestle, and our doctors selling Nestle baby formula and Gerber’s baby food (which Nestle owns) to us out of their offices. Instead of going shopping for our children at the supermarket, we go to our doctor’s offices – because our doctors warn us of the dangers of making our own food and meals for our babies – after all, the science of their nutrition is complicated. Our doctors explain to us that fresh food is dangerous for our children. It’s best for our children to eat the nutritionally balanced, highly processed diet despite our concerns over ingredient quality and the use of a long list of synthetic vitamins to make up for what’s been destroyed in the process of making the food. Not only that – but then our children go on to eat the adult formulas – and eat nothing but highly processed foods their entire lives.

…except our doctors don’t tell us that, do they? They tell us to eat a minimally processed diet with whole fresh foods for our best health. They tell us to eat a balanced diet – balanced meaning, the “right” amount of each food group – protein, fruits, vegetables, grains, and dairy products – based on the USDA food pyramid or the updated “My Plate”. (44) They tell us our nutritional needs will be met if we eat a wide variety of fruits, vegetables, grains, and protein sources. I wonder why vets don’t use something similar for our cats?

Of course, a variety of meats and cuts are usually easy for most of us to obtain. A variety of organs? Not so much. So yes, most homemade raw cat food recipes include some supplementation (though some of that is to account for what is provided by the parts of the animals we don’t feed). But the time-tested balanced recipes are all based on this simple prey model – because even when compared to AAFCO and FEDIAF nutrient requirements (which are designed to ensure the very highly processed diets meet cats’ needs despite nutrient damage from processing and heat) this is what cats need.

So What Does My IBD Cat Need Nutritionally?
“The justification for nutritional management of IBD is twofold. First, dietary factors may contribute to the initiation or perpetuation of the disease. Second, malnutrition is a common sequela to IBD due to anorexia, malabsorption and increased nutrient losses.”
~ Small Animal Clinical Nutrition, p 1071 (45)

First and foremost, IBD cats need a species-appropriate diet comprised of high-quality, meat-based proteins and fats. In fact, according to the Small Animal Clinical Nutrition textbook, our IBD cats need (46):

⦁ A moisture-rich diet. Dehydration is a frequent problem in cats with IBD. Kibble is not an appropriate food format for any cat, but especially not IBD cats that need the least amount of strain on their inflamed, impaired gastrointestinal systems.

⦁ Electrolytes. With chronic vomiting and/or diarrhea, low circulating serum blood levels of potassium are common. Foods containing 0.8% – 1.0% potassium on a dry matter basis are recommended.

⦁ A medium-to-high energy dense diet is ideal, but often not practical. These foods enable a smaller volume of food to be fed in order to “minimize GI distension and secretions.” It is noted that unfortunately “energy dense foods are high in fat, and high fat foods can contribute to osmotic diarrhea and GI protein losses.” What they don’t say is that fat is more complicated to digest, and anecdotal evidence suggests that many IBD cats need lower fat diets due to fat malabsorption, often a cause of very stinky bowel movements. Further, it is very important to note that research published in 2014 (the textbook was written in 2010) indicates that fat digestibility is lower in cats with low vitamin B12. So IBD cats with low B12 will likely do best on a high protein, low fat diet until B12 shots return blood serum levels of B12 to normal. (47)

⦁ High Protein: a minimum of 35% protein on a dry matter basis. Protein malnutrition is common in IBD cats due to damage to the GI tract from inflammation and the impaired ability to efficiently metabolize proteins – it is also due to losses from chronic diarrhea and/or chronic vomiting.

⦁ A highly digestible diet. IBD cats need food that is easy to metabolize, because their intestinal tracts are already impaired. The minimum protein digestibility recommended is 87%. I note: that rules out ALL dry food. Experiments conducted to evaluate the protein quality of fresh versus rendered animal by-products commonly used in pet foods found that total essential Amino Acid (AA) digestibility ranged from 93.6 to 96.7 for the raw ingredients, and 79.2 to 84.8% for rendered animal feed ingredients. (48)

⦁ Low fiber. The textbook notes that while fiber can help normalize transit time through the small bowel, the level of fiber required to reduce a “hypermotile” state reduces both energy density and digestibility of the food. It is also noted that in humans with IBD, a “small amount” of fermentable fiber has been shown to promote the growth of healthy bacteria (Bifidobacterium and lactobacillus). The problem that isn’t addressed in this textbook? Cats have one of the shortest GI tract-to-body lengths in the animal world. They are not “built” to ferment fiber. Yes, there are studies indicating fiber given to cats promotes the growth of healthy bacteria. We can achieve the same thing by simply providing them with known, researched strains of probiotics. Please see Probiotics for Cats: Human Grade Probiotics Instructions, here: www.ibdkitties.net/probiotics/.

⦁ Nutrient/Vitamin-Rich Food. Water soluble vitamins are obviously of concern in cats losing moisture via frequent vomiting and diarrhea:

⦁ B12 (cobalamin). It is noted that a B12 (cobalamin) deficiency is common in cats with IBD. B12 shots are recommended. An important note: research published in 2013 indicates that chronic diarrhea associated with IBD when there is low serum cobalamin (B12) will NOT resolve until B12 levels are normalized. (49) www.ibdkitties.net/the-importance-of-b12/.

⦁ Sufficient thiamine. It is noted that thiamine deficiency occurs commonly “and can profoundly affect appetite.”

⦁ Zinc. A zinc deficiency is “well recognized in people” as a complication of IBD. It is suggested that if cats with IBD have poor coat quality or dermatitis that zinc supplementation be considered. This should ONLY be done in consultation with your veterinarian, as cats are very sensitive to zinc and at relatively low levels it is toxic to them and can cause severe anemia and multiple organ failure leading to death.

⦁ Omega 3 fatty acids. While there is little research in dogs and cats regarding the role of omega 3s in IBD, there is clinical evidence in people that not only do omega 3s help control the inflammation of the GI tract, it appears that omega 3 fatty acids act as competitive agonists to pathogenic bacteria. We note that if omega 3 fatty acids are to be supplemented, they need to be in the form of fish oils, krill oil or green lipped mussel oil or powders are recommended as they are in a phospholipid base which makes them more bioavailable – they also have higher levels of antioxidants than other fish oils and thus are less susceptible to oxidation. Rancid fats and omegas in pet foods are thought to contribute to the development of kidney disease. If you wish to add these to your pet’s diet, as with anything new, please introduce them slowly.

What does “highly digestible” mean?
Food digestibility and nutrient bioavailability are at the heart of nutrition. Digestibility is a measure of how much nutrition a food provides in a given volume. It indicates how much of the food is absorbed by the gut (intestines) into the bloodstream. It is the difference between what your cat eats and what your cat excretes.

Nutrient bioavailability is the proportion of the absorbed nutrients that are carried to target tissues and are available for use by the body. Because a highly digestible food provides a higher proportion of absorbed nutrients than a less digestible food, digestibility provides an important measure of a food’s nutritional value and quality. In general, as the quality of ingredients in the food increases, so will the food’s digestibility and nutrient bioavailability.

Merriam-Webster defines digestibility as “the percentage of foodstuff taken into the digestive tract that is absorbed by the body.” (50) Simply put, it is the difference between how much food your cat eats and how much is excreted in stool. What they can’t digest, they excrete.

Example: your cat eats one 5.5 ounce can of food a day. Your cat excretes 0.8 ounces of stool. That means your cat digested 4.7 ounces of the food she ate.  4.7 ounces of food absorbed divided by 5.5 ounces of food eaten = 85%. This food is 85% digestible. Yes, water is a factor, but not one we have to worry about unless comparing canned and kibble. The point is the difference between what they eat and what comes out is what is meant by “digestibility.”

On the left:
Food:  High protein (meat by-products), low carbohydrate canned with guar gum, food coloring and “natural” flavors
Amount:  4.5 ounces per day.
Frequency of stool:  Daily

On the right:
Food:  Homemade raw food made with EZcomplete fur Cats using beef as the boneless muscle meat.
Amount:  4.5 ounces per day
Frequency of stool:  Every-other-day

Why does this matter? What does this illustrate?

Let’s look at protein, being so important to a cat. To determine the digestibility of protein (or any individual nutrient), the amount of the individual nutrient in the stool is determined. So if that 5.5 ounce can of food contains 19 grams of protein, and kitty excretes 3 grams of protein in the stool, kitty used, kitty absorbed, kitty metabolized 16 grams of protein. 16 grams of protein absorbed divided by the 19 grams of protein eaten = 84%. The protein in that food is 84% digestible. But different protein sources have differing digestibility due to their biological values, and different foods have varying ingredients that make the protein more or less accessible to the body.

Example: Canned foods 1 and 2 both have 12% protein as listed on the guaranteed analysis. They both have the same moisture content of 72%. This means each 5.5 ounce can of food has about 19 grams of protein.

Food 1 has a digestibility of 90%
Food 2 has a digestibility of 80%

Food 1: 19 grams x 90% = 17 grams of protein absorbed by the body
Food 2: 19 grams x 80% = 15 grams of protein absorbed by the body

Even though each can of cat food is labeled as having 12% protein and 72% moisture, and we expect they will provide the same amount of protein to our cat, they don’t. Food 1 provides more protein than Food 2.

If we presume both canned foods have the same protein as the main ingredient, how can there be such a big difference in digestibility? Digestibility is impacted by many factors apart from protein sources, though protein quality is an important factor in digestibility of the food and bioavailability of the nutrients. Differences arise from protein source, protein quality, the macronutrient content, other ingredient differences of the foods: the presence (or lack) of fiber, gums or thickeners, particle sizes, processing techniques, the temperatures achieved in processing – and, of course, the age and health of the animal eating the food (51).

What Is a “High Quality” Protein?
First, we need to understand that not all proteins are created equal, especially when feeding an obligate carnivore. As Mark Peterson, DVM (renowned small animal endocrinologist) says, “The biological value of a protein is a measure of that protein’s ability to supply amino acids (especially the 11 essential amino acids required by cats) and to supply these amino acids in the proper proportions. It is well-established that animal proteins (e.g., meat, meat by-products) have higher biological values than vegetable proteins (e.g., corn gluten meal, soybean meal, soy protein isolate).” (52)

High quality protein is animal-based. High quality protein provides the 11 essential amino acids in proper proportions. The highest quality proteins come from fresh, raw human grade meats, not cooked meats, and not pet grade meats, which include diseased and downed animals in both canned and kibble cat foods. (53)

So how do we know which foods are highly digestible and provide the most nutrition to our cats?

Kerr at al 2012. Apparent total tract energy and macronutrient digestibility and fecal fermentative end-product concentrations of domestic cats fed extruded raw, beef-based and cooked beef-based diets. J Anim Sci 2012, 90:515-522 (Ref 54)
Hamper et al 2015. Apparent nutrient digestibility of two raw diets in domestic kittens, J Feline Med Surg 2015 Sep 23 (Ref 55)

As you can see in the table that summarizes food format research done in cats, raw food – the food format cats naturally eat – is easiest for them to fully utilize. Does that really come as much of a surprise? When discussing cat food, “high quality food” starts by being a food that is appropriate given the cat’s physiologic and metabolic needs. This is called “species appropriate” or “biologically appropriate” food. It refers to “high” protein, extremely low carbohydrate, low fiber food comprised of fresh, minimally processed meat and organ (a source of calcium and the minimum of other ingredients needed to make it nutritionally complete). This diet, this food will provide the most easily accessible nutrition.

It is even more important for cats with inflammatory bowel disease that they eat high quality, species-appropriate food as that places the least stress on their systems. That diet is­;

Comprised of whole, fresh human grade animal-based proteins and fat. This means homemade raw or a few commercial raw foods. Homemade cooked is also an option, though cats do best with the naturally occurring enzymes in raw food. Cooking destroys these enzymes and increases stress on the pancreas. Please note, many foods, even canned foods and foods marketed as “grain-free” contain non-meat based proteins such as soy or peas. These cost less than meat and that is the only reason they are there: to increase the apparent protein level of the food. Almost all commercial canned and kibble cat foods contain pet grade (waste product) meats and other ingredients, regardless of those pretty marketing pictures.

Moisture-rich. Feeding moisture-depleted dry food, especially if it is free-fed, as discussed has resulted in alarming health problems in our cats, with obesity, periodontal disease, lower urinary tract diseases and kidney disease literally plaguing – and killing – our cats. In fact, the heat required to create kibble creates carcinogens – the last thing any cat, *especially* an IBD cat, should eat. (56)

Why No Dry Food. There are a myriad of problems with dry food for pets, especially cats. They are discussed at length by many: Dr. Elizabeth Hodgkins (former head of Technical Affairs for Hill’s Pet for over a decade), Dr. Lisa Pierson, Dr. Jean Hofve, and Dr. Karen Becker, to name a few. But there is one over-arching reason to avoid dry food for our cats – especially our IBD cats: the heat needed to produce kibble creates a compound that in humans is linked to inflammation, rapid aging, Alzheimers, and cancer – notably gastrointestinal cancer and colorectal cancer. These are a by-product of the Maillard reaction, and are called advanced glycation end-products. As Dr. Becker explains, “When a protein joins with a carbohydrate, the biochemical result is a compound that can cause widespread inflammation and damage in the body.

Advanced glycation end products have been extensively studied in humans, and have been shown to exacerbate diabetes and interfere with kidney function. AGE has also been linked to aging, Alzheimer’s disease, cancer, and more recently, neurologic disease such as intervertebral disc disease.

AGE studies in humans have revealed that we make the compound in our bodies, but we also have mechanisms to deal with it. However, if we eat a diet high in processed foods, it increases the level of AGE in our bodies.

A direct link exists between the amount of processed foods consumed and the level of AGE in the blood. The reverse is also true: eat foods low in AGE and AGE blood levels decrease. In fact, studies show that when people with diabetes eat a low AGE diet, it improves insulin sensitivity and kidney function.” This quote is from an article by Dr. Becker who interviewed another vet examining AGEs in pet food. The pilot study, which examined pet foods for AGEs found them –and found that there is a direct link between processing and the presence of advanced glycation end-products. The study found consistently in the pet food examined that “the less processing that occurs, the less heat applied, the more moisture maintained, the lower the AGE.” As IBD increases the risk that our cats will develop intestinal lymphoma, obviously removing potential carcinogens from their diet should be considered important, if not imperative.

Please see reference 56 for further links and information.

Minimally processed. We know from human nutrition it is healthiest if nutrients are consumed in their natural, unprocessed, form. Not only can processing damage nutrients but science is starting to understand the importance of consuming some nutrients at the same time and in the same quantities as they naturally occur. The more we provide nutrients in an unnatural form, the more likely we are providing them in a less than optimal manner just because of things we don’t know. It is pure hubris to believe we have anywhere near a complete understanding of feline nutrition, and our cats are suffering because we feed them a highly processed diet with synthetic vitamins replacing those damaged by the process of making their food. We see it time and again in cats with inflammatory bowel disease. We rip out our hair trying to identify a novel protein that doesn’t trigger problems – when all along, the problem was the combination of ingredients or the processing of the food, not the protein! When given fresh and human grade, many cats that were “allergic” to chicken are almost magically no longer sensitive to the protein. Yes, some need organic, non-GMO fed meat.

If you opt to feed canned food, it is best for your IBD cat if you look for a food that is

Made with high quality protein. That means no by-products. Named organ (like liver) is actually good for kitty. But look for food that has only named meat, no by-products, best if there is just one type of protein, and it is best to avoid fish.

Low in carbohydrates. Cats will overeat high carbohydrate foods in an attempt to derive enough protein, as energy from carbohydrates cannot replace their need for energy from protein. (57) This puts them at risk for obesity, diabetes, and many GI disorders (principally fatty liver disease, inflammatory bowel disease and pancreatitis).

Low in fiber. Unless a cat has an already damaged intestinal tract, a cat does not need fiber in the diet. Cats have one of the shortest GI tract-to-body lengths in the animal world: unlike humans, they are not physiologically meant to ferment fibers and their natural diet contains almost no plant-based fiber. (58) Fiber produces bulky stools, and cats naturally pass very small, firm, odorless stool.

It is also important the food you choose has;

No, or very little fruits and vegetables. If there are any, they are less than 5% of the total food and there only for antioxidant support. Only low glycemic vegetables (that are safer for cats to eat) should be used.

No thickeners or at the very least a bare minimum of thickeners. It is nearly impossible to find a canned food without some form of thickener, whether it is tapioca, potato starch, guar gum, locust bean gum, agar-agar, xanthan gum, carrageenan or the many others used. In humans, many of the thickeners have been linked to the development of inflammatory bowel disease, via dysregulation of the gut flora. Notable among them are carrageenan, xanthan gum, and maltodextrin (which is generally not used in pet foods, but is in many supplements as a flow agent in small amounts – in human foods it is far more prevalent and in much larger quantities. It is also known as “modified food starch”). (59)  Carrageenan is a particularly nasty ingredient. It is a red algae-derived polysaccharide that according to the International Agency for Research on Cancer (IRAC) shows “sufficient evidence for the carcinogenicity of degraded carrageenan in animals to regard it as posing a carcinogenic risk to humans.” (60) Of course, non-degraded carrageenan is used in human and pet foods. But as you can see from the discussion in the link for the reference, the process of digestion can degrade carrageenan. Not so safe once digested!

Summary
The importance of feeding a cat with inflammatory bowel disease – in fact, all cats – a highly digestible, species appropriate diet cannot be ignored nor overstated, not only for its nutritional aspect, but also for the strain a highly processed diet puts on the entire digestive system of the cat in trying to digest food that is devoid of natural nutrients and enzymes, which ultimately results in inflammation. Of course it makes sense an IBD cat needs the least inflammatory diet possible. Many of the top diseases our cats suffer, including IBD, are directly related to their diets – and if not caused by them, then exacerbated by them – and can often be avoided or mitigated by providing them with whole food-based nutrition.

Adapted from articles originally published on www.foodfurlife.com/#oid=26787_2477

REFERENCES

1) Carbs were key in wolves’ evolution into dogs, Los Angeles Times, January 23, 2013. http://articles.latimes.com/2013/jan/23/science/la-sci-how-dogs-evolved-20130124
2) Morris, JG. 2002. Idiosyncratic nutrient requirements of cats appear to be diet-induced evolutionary adaptations, Nutrition Research Reviews, Vol 15:01, June 2002, pp 153-168. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=607588&fulltextType=RA&fileId=S0954422402000070
3) Eisert R 2011. Hypercarnivory and the brain: protein requirements of cats reconsidered, J Comp Physiol B. 2011 Jan;181(1):1-17. http://www.ncbi.nlm.nih.gov/pubmed/21088842
4) Adamec R 1976. The interaction of hunger and preying in the domestic cat (Felis catus): An adaptive hierarchy. J Behav Biol 1976 Vol 1(2) 263-272. http://www.sciencedirect.com/science/article/pii/S0091677376921660
5) Morris 2002.
6) Peterson, M 2011. Can Increasing the Amount of Fat or Carbohydrate in a Cat’s Diet Compensate for Low Protein Intake? Insights into Veterinary Endocrinology blog. Dec 22, 2011. http://www.endocrinevet.info/2011/12/can-increasing-amount-of-fat-or.html
7) Morris 2002.
8) IBID
9) Hofve, J 2015. Supplements Every Pet Needs. Featured in IVC Journal, Nutrition Nook, Summer 2015. http://ivcjournal.com/nutrition-nook-supplements-every-pet-needs/
10) Bernard, M, Raising Cats Naturally: How to care for your cat the way nature intended. Blakkatz Publishing 2003.
11) Sinclair AJ et al 1979. Metabolism of linoleic acid in the cat. Lipids 1979 Nov; 14(11):932-6. http://www.ncbi.nlm.nih.gov/pubmed/513981
12) Morris 2002.
13) Morris, JG 2002. Cats discriminate between cholecalciferol and ergocalciferol, J Anim Physiol Anim Nutr (Berl) 2002 Aug;86(7-8):229-38. http://www.ncbi.nlm.nih.gov/pubmed/15379909
14) Hewson-Hughes AK et al 2011. Geometric analysis of macronutrient selection in the adult domestic cat. J Exp Biol 2011 214: 1039-1051. 15) http://jeb.biologists.org/content/214/6/1039.full#R22
15) Peterson 2011
16) Wortinger A 2010. Cats: obligate carnivore (Proceedings). CVC in Kansas City Proceedings, August 1, 2010. http://veterinarycalendar.dvm360.com/cats-obligate-carnivore-proceedings?id=&sk=&date=&%0A%09%09%09&pageID=2
17) Hofve, J 2012. Digestive Enzymes, Featured in I VC Journal Spring 2012. http://ivcjournal.com/digestive-enzymes/
18) Wortinger 2010
19) Phillips-Donaldson 2016. Global pet food trends: sales and volume rose 4% in 2015. Adventures in Pet Food blog at Petfoodindustry.com http://www.petfoodindustry.com/blogs/7-adventures-in-pet-food/post/5609-global-pet-food-trends-sales-and-volume-rose-4-in-2015
20) Kays and DeWan 2004. Ecological impact of inside/outside house cats around a suburban nature preserve, J Anim Conserv Vol 7(3) Aug 2004:273-283. http://onlinelibrary.wiley.com/doi/10.1017/S1367943004001489/abstract
21) Pierson L. 2013. Feeding Your Cat: Know the Basics of Feline Nutrition. http://www.catinfo.org/
22) Adolph EF 1947. Tolerance to heat and dehydration in several species of mammals, Am J Physiol 1947 Dec 1;151(2):564-75. http://www.ncbi.nlm.nih.gov/pubmed/18901899
23) VPI – Veterinary Pet Insurance Top 10 Cat Medical Conditions in 2015. http://www.petinsurance.com/healthzone/pet-articles/pet-health/Top-10-Cat-Medical-Conditions.aspx
24) Food Fur Life. Water – An Essential Nutrient for our Cats’ Health. http://www.foodfurlife.com/water—the-essential-nutrient.html
25) Banfield State of Pet Health 2013 Report. http://www.banfield.com/Banfield/media/PDF/Downloads/soph/Banfield-State-of-Pet-Health-Report_2013.pdf
26) Longevity & Causes of Death in Pet Cats, March 9, 2015 at The SkeptVet blog. http://skeptvet.com/Blog/2015/03/longevity-causes-of-death-in-pet-cats/
27) Banfield State of Pet Health 2013
28) Pet Obesity Prevention http://www.petobesityprevention.org/
29) Banfield State of Pet Health 2013
30) IBID
31) Armstrong, PJ 2009. Diabetes mellitus in cats: Risk factors and treatment (Proceedings). CVC in Washington DC Proceedings 2009. http://veterinarycalendar.dvm360.com/diabetes-mellitus-cats-risk-factors-and-treatment-proceedings
32) Banfield State of Pet Health 2013
33) VPI Top 10 Cat Medical Conditions 2015
34) Plantinga et al 2011. Estimation of the dietary nutrient profile of free-roaming feral cats: possible implications for nutrition of domestic cats, Br J Nutr 2011 Oct; 106 Suppl 1:S35-48. http://www.ncbi.nlm.nih.gov/pubmed/22005434
35) Haselbush WC 1984. Mark Morris Veterinarian, R.R. Donnelly & Sons Company.
36) Roach M 2013. The Chemistry of Kibble: The Billion-dollar cutting edge science of convincing dogs and cats to eat what’s in front of them, Popular Science, April 2013. http://www.popsci.com/science/article/2013-03/chemistry-kibble
37) Susan Thixton, Truth About Pet Food The Truth about Why Dead/Diseased Animals goes to Pet Food, (March 25, 2016). http://truthaboutpetfood.com/the-truth-about-why-deaddiseased-animals-goes-to-pet-food/ Also see The Official Unofficial Dumping Ground, August 23, 2016. http://truthaboutpetfood.com/the-official-unofficial-dumping-ground/
38) FDA Compliance Policy Guide CPG Sec. 675.400 Rendered Animal Feed Ingredients “No regulatory action will be considered for animal feed ingredients resulting from the ordinary rendering process of industry, including those using animals which have died otherwise than by slaughter, provided they are not otherwise in violation of the law.” http://www.fda.gov/ICECI/ComplianceManuals/CompliancePolicyGuidanceManual/ucm074717.htm
39) FDA Compliance Policy Guide CPG Sec. 690.300 Canned Pet Food “Pet food consisting of material from diseased animals or animals which have died otherwise than by slaughter, which is in violation of 402(a)(5) will not ordinarily be actionable, if it is not otherwise in violation of the law. It will be considered fit for animal consumption.” http://www.fda.gov/ICECI/ComplianceManuals/CompliancePolicyGuidanceManual/ucm074710.htm
40) Haselbush 1984
41) Mark Morris Institute website: Teaching Programs http://www.markmorrisinstitute.org/programs.html
42) Freedom of Information Enquiry 2007 Royal School of Veterinary Studies, University of Edinburgh. http://www.ukrmb.co.uk/images/EdinburghFOI2007.pdf
43) Hand et al 2010. Small Animal Clinical Nutrition, 5th Edition; Mark Morris Institute, Topeka, KS pp 1068-71.
44) IBID
45) Salas et al 2014. Fat digestibility is reduced in old cats with subnormal cobalamin concentrations, J Nutr Sci 2014 Dec 30;3:e62. http://www.ncbi.nlm.nih.gov/pubmed/26101630
46) Cramer et al 2007. Protein quality of various raw and rendered by-product meals commonly incorporated into companion animal diets, J Anim Sci 2007 Dec;85(12):3285-93. http://www.ncbi.nlm.nih.gov/pubmed/17609474
47) Kook PH 2013. Cobalamin in gastrointestinal disease, North American Veterinary Conference, Orlando, U.S., 19 January 2013 – 23 January 2013. http://www.zora.uzh.ch/72883/1/Kook_2013_NAVC_Cobalamin_in_GI_disease.pdf
http://www.merriam-webster.com/dictionary/digestibility#medicalDictionary
48) Hamper et al 2015. Apparent nutrient digestibility of two raw diets in domestic kittens, J Feline Med Surg. 2015 Sep 23.
49) Peterson, M 2011. Optimal Protein Requirements for Older Cats and Cats with Hyperthyroidism, Insights into Veterinary Endocrinology blog. Nov 7, 2011. http://www.endocrinevet.info/2011/11/optimal-protein-requirements-for-older.html
50) Thixton, S. What is the difference between Human Grade/Quality and Pet Grade/Quality Pet Food Ingredients? http://truthaboutpetfood.com/what-is-the-difference-between-human-gradequality-and-pet-gradequality-pet-food-ingredients/ and references 38, 39 and 40.
51) Kerr at al 2012. Apparent total tract energy and macronutrient digestibility and fecal fermentative end-product concentrations of domestic cats fed extruded raw, beef-based and cooked beef-based diets. J Anim Sci 2012, 90:515-522. http://www.2ndchance.info/homemadediets-Kerr2012.pdf
52) Hamper 2015
53) Becker, K 2015. Blog, Dec 10, 2015. “Finally! A Study that Proves Processed Pet Food Can Cause Disease.” http://healthypets.mercola.com/sites/healthypets/archive/2015/12/10/processed-pet-food-causes-disease.aspx
Also see:
Kuniyasu et al 2001. Expression of receptors for advanced glycation end-products (RAGE) is closely associated with the invasive and metastatic activity of gastric cancer, J Pathol Vol 196, issue 2, 2002 February 163-170. http://onlinelibrary.wiley.com/doi/10.1002/path.1031/full
Yamagashi et al 2005. Possible participation of advanced glycation end products in the pathogenesis of colorectal cancer in diabetic patients, Med Hypotheses. 2005;64(6):1208-10. http://www.ncbi.nlm.nih.gov/pubmed/15823719
The problems with dry food:
Dr. Hodgkins: Review of the book by Dr. Hodgkins by Ingrid King of The Conscious Cat: http://consciouscat.net/2010/04/02/book-review-your-cat-simple-new-secrets-to-a-longer-stronger-life-by-elizabeth-m-hodgkins-d-v-m-esq/
Dr. Lisa Pierson: http://catinfo.org/
Dr. Jean Hofve: http://www.littlebigcat.com/nutrition/why-dry-food-is-bad-for-cats-and-dogs/
Dr. Karen Becker: http://healthypets.mercola.com/sites/healthypets/archive/2015/11/08/best-to-worst-pet-food-types.aspx
Feline-nutrition.org: http://feline-nutrition.org/health/species-inappropriate-the-dangers-of-dry-food
56) Peterson 2011
57) Plantinga 2011
58) Nickerson et al 2015. Deregulation of intestinal anti-microbial defense by the dietary additive, maltodextrin, Gut Microbes. 2015; 6(1): 78–83. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4615306/
59) The Cornucopia Institute, Carrageenan: An ingredient linked to gastrointestinal inflammation, classified as a “possible carcinogen.” http://www.cornucopia.org/tell-the-usda-to-remove-carrageenan-from-organic-foods/

Refusing to follow any of these guidelines are grounds for, removal and/or blocking. Depending on the number of rules broken and/or the offense you may be suspended for up to 30 days, whereas you won’t be able to participate but you’ll still be in the group. Extended explanation for guidelines follows at the end of these rules (Please read all).

• We are NOT veterinarians. We cannot and WILL NOT diagnose your cat! We understand it’s not always feasible to get your kitty to a vet for various reasons. But we cannot take the place of proper veterinary care and proper diagnostics. Always check with your vet before making changes to medications and/or treatment.
• NO posting about unknown cats. If it’s not your cat, a cat in your care (including ferals), or a cat belonging to your extended family, it will be removed. Only questions and concerns about cats. Not dogs, no other animals.
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• DO PLEASE post links from my website first, IBDKITTIES.NET and check the website for information before posting questions.

Extended Explanations for Guidelines (optional to read)

BE ADVISED: The group admins are asking that you DON’T message us unless there is a REAL EMERGENCY that for some reason only we can help. If you have a problem in the group or with another member, flag the post, it’s easy. Go to the top right where the three dots are and click on flag post. We will see it and decide how to deal with it, please respect whatever decision we come to. If you have a health question, again, ask in the group. Messaging an admin to complain about the rules & guidelines will also be grounds for removal. When you join this group you clearly state you’ve read them and agree to follow the rules. If you don’t like them you’re welcome to leave the group at any point, it’s not up for negotiation. Thank you for your cooperation.

This group is for people that have or have had kitties with IBD, fatty liver disease, pancreatitis or any other GI disorder. Anyone is welcome to join our group as long as you abide by the rules we welcome everyone who wants to learn, help others, or needs help.

• We are NOT veterinarians. Always check with your vet before making changes to medications and/or treatment. Any suggestions made in the group regarding medications, supplements, treatments, diet, etc. are only that…suggestions, and should not be regarded as medical advice.
• Research material, theories, experience, etc. are all welcome. However, we are not here to persuade, confuse, argue, intimidate or scare others into our views or opinions. Please refrain from arguing an issue to the point of exhaustion. Be respectful of each other’s opinions and feelings, state your point and move on. Bullying will not in any way be tolerated and that includes towards the admins.
• NO food shaming. We are here to offer support and education, but not pressure. Every cat is different and there are no “one size fits all” treatments or answers. What works for one or several others may not work for another and it is ultimately the pet parent’s decision to make regarding what kind of diet, treatment, medication, supplements, etc. that they are willing to give their pet.
• We do not in any way advocate vegan or vegetarian diets for cats. Cats are obligate carnivores and if not fed meat they are in serious danger of anemia, B12 deficiency, etc. We will not advocate vegan/vegetarian diets here and any posts regarding these diets will be removed and possibly the member as well if they push it. Sorry but that’s life threatening. All homecooked or raw fed diets must be supplemented and/or balanced, it can be life threatening otherwise.
• There is presently NO cure for IBD. There are many great treatments and there is “remission” but there is currently NO CURE. We ask that you refrain from this statement as it gives false hope.
  • We are NOT a holistic group and will not allow the discussion of such. We see A LOT of pages, groups and posts, etc. on holistic treatments that are unsafe, have no proven science behind them, and are not researched and proven safe. There are many gray areas concerning holistic treatments and we just don’t have the time or resources to debate the issue constantly. If you are interested in alternative or holistic treatments for your cat you should consult with a registered holistic vet. Because such treatments are tailored to a specific cat or complaint we ask you not to share such remedies with the rest of the group as they may not be suitable for their cat.
  • Any discussions on essential oils is prohibited as we feel it’s unsafe (regardless of the amount of attention and/or selling of these items by vets etc.). Please see this link for further information on why it’s unsafe: https://www.ibdkitties.net/supplements/toxicunsafe-natural/.
  • Coconut oil should not be taken internally by cats; Cats cannot filter MCTs (medium chain triglycerides). https://www.ibdkitties.net/supplements/toxicunsafe-natural/
  • Alcohol of any kind in products is not safe. Cats cannot process it. https://www.ibdkitties.net/toxicunsafe-foods/.
  • Homeopathics and Chinese medicine are extremely individual to each cat and like other things should be discussed with your holistic vet. We state again that these should not be brought up or shared in the group in any way.
  • CBD oil is very popular and while we respect this and allow the discussion of it, we cannot recommend it due to the problems with counterfeit products, lack of testing in cats and/or science behind it. CBD oil can interfere with some medications and like anything else can have side effects to it. While we are fine with it, we’d prefer it not become the lead discussion in the group. https://www.ibdkitties.net/using-cbd-products-information-and-resources/
  • Allowed discussions include slippery elm bark (it’s pure fiber, nothing else), George’s fractionally distilled aloe vera liquid (not latex so safe for cats), milk thistle (which is prescribed by vets as it’s an ingredient of Denosyl and Denamarin, collagen to build muscle and help weight gain, probiotics/prebiotics etc. Anything along these lines.
• Try to use resources within the group and within the IBDKitties website first, before referring members outside the group unnecessarily. We see A LOT of people posting links to other groups when there really isn’t a need. If a kitty has been diagnosed with cancer or kidney disease, etc., we absolutely have no problems with recommending specialty groups. Always check the IBDKitties website first if you have a question, especially if you are new to IBD. Answers to many common questions are there. In fact it would be helpful if people would post links to my site for referneceas we’ve worked hard on it. https://www.ibdkitties.net/. Please also do a search in the group for certain subjects before posting if at all possible. There are THOUSANDS of posts on many subjects. 
• Please try and include as much information as you can in one post. Posting each question you have separately every few minutes takes up the forum and gets very confusing. We have THOUSANDS of members and won’t be able to remember what you posted days ago or your cat’s history.
• There are many people who very generously want to donate medications, which can be expensive, to members of the group. Unfortunately due to strict laws, we cannot allow donation or selling of medications within the group. Doing so is against the law and we could be reported which would hurt everyone in the group. For this reason only food, supplies and non prescription supplement posts will be allowed. We apologize as we need to think about the safety of everyone involved.
• NO private PMs to other members. It has led to harrassment, misinformation & disrespect for the members, admins and the group. We will allow it when giving away supplements, food & supplies but for no other reason. Those posts will be immediately removed without explanation. If it continues that’s grounds to be removed and blocked.
• Do not hijack other people’s posts in order to discuss your kitty. We appreciate you answering the questions asked or giving your experience when it applies but if you need help, we want you to start your own thread. The person who originally posted has the right to have the attention focused on their needs at the time.
• In order to keep things easy to find and flowing for all members, refrain from posting off-topic material and keep to the subject matter. This includes random articles not associated with the subject matter, photos of unknown pets and graphics. Random graphics (funny, cartoons, etc) are not allowed as it easily gets out of hand and causes questions from members to get pushed down out of sight so they don’t get answered. Also, it’s fine to post occasional pictures of your kitty without questions or advice, but please don’t flood the forum with pictures only. We want to keep the forum clean and flowing for people to find subject matters easily. If these things are posted they will be immediately removed and you will be contacted with a reminder to read the guidelines again.
• Vomit, poop, bloody or anus pictures of any kind are not allowed as some of us are very squeamish, these pictures will be removed. Pictures like this should be sent to your vet for them to determine if a vet visit is in order.
• No posts about rehoming, posts about abused animals, petitions, etc. Respect that this is a group solely for feline IBD and related conditions and anything posted to the contrary will be immediately removed.
• Fundraising links will not be allowed nor selling products, promoting your pages, etc. And especially, if you start another group with similiar feline issues, I’m sorry but it’s rude to post a link in MY group sending people to yours’. Just not cool.
• IBDKitties members are welcome to join our bereavement group if you’ve experienced loss of a pet or a human. https://www.facebook.com/groups/IBDKittiesGriefSupport/ We’re better equipped to help you through your extreme grief and can concentrate on that particular subject matter. We hope you understand that the pet parents here in the regular group are in a delicate state with their own pets and it can become too much sometimes to see the extreme grief you are going through every day. Be aware that the bereavement group is restricted to members of IBDKitties and we will not accept outside members. If you’re in the regular IBD group and want to leave but join the grief group, please join the group first as you won’t be allowed in once you leave IBDkitties.
• Do not to post pictures or video of your kitty’s body after it’s passed or getting ready to pass. Many people here are on the edge with anxiety and some have PTSD after watching their kitties pass away or being so sick. We aren’t trying to be insensitive, quite the opposite. We know that many different cultures and places around the world handle death differently but not everyone can handle it.
• All health- related questions should be asked in the group only. We ask that you refrain from PMing admins for personal opinions and one-on-one help. There are many more members in the group itself that can offer you help and in fact probably know more about certain conditions than we sometimes do. We are not here 24/7 and cannot keep up with these requests. If you’re reporting a post for any reason then please flag it.
• You may not block any of the admins. If we see that you have, you will promptly be removed and blocked from the group. We cannot have people blocking us because you don’t like the rules or anything we’ve said in the group; we need to be able to converse with you for many different reasons. Simple as that.

IBDKitties reserves the right to remove any member without warning for not following these guidelines and to change or add to the guidelines in the future. Thank you for understanding and following these guidelines! Anyone who feels someone is violating the guidelines should feel free to report the post and we will determine what happens next.

This group is a sister page to the website https://www.ibdkitties.net/. Please refer to this site for information, case studies, research, etc.

Thank you for your cooperation.

By Lisa Provost

When Alex died in 2008, I never would have believed it could get so much worse; but it has. I used to think we were making progress on treatments, diets, medications, etc. But now it’s time to get serious because there isn’t enough research and it’s not happening fast enough. These cats are being poisoned by so many things; just like we humans. But their systems are nothing like ours, they are quite fragile beings. And we’re losing them. There are so many more facets to IBD now it’s dizzying sometimes.

The truth is there is no easy answer because IBD is a trickster, a shape shifter, an ever-changing face like Jeckyll and Hyde. How do you go into battle with something like that? And make no mistake about it; it IS a battle…a constant roller coaster of ups and downs. The stress from this disease can take its toll on both you and your pet. Some days you feel like they’re finally turning the corner and you’re able to exhale. Then without warning, things change and you’re trying to figure out what happened and how to fix it. Its frustrating, exhausting and can leave pet parents feeling helpless and hopeless. I hope this website serves you well with information, a better way handle this disease and maybe a little relief knowing you aren’t alone in this.

I’m often asked if there are any statistics, if it’s known how long an IBD kitty can live. The absolute truth is there are no statistics at all and every single cat reacts very differently to each treatment. It may sound like an cop out or exaggeration to say this, but it’s far from it. Which is why it’s so hard to develop any kind of protocol with this disease. One thing will work for one cat, and not at all for the other. It’s pretty much a gamble and one you have to take in order for them to recover. It’s daunting, but you have to keep trying. Know there is support and you are definitely not alone.

What is IBD:
Feline Inflammatory Bowel Disease (IBD) is a group of disorders that cause inflammation in the lining of the stomach and/or intestinal tracts, basically changing how these organs perform their normal bodily functions. IBD is an uncontrolled inflammatory response, causing the inflow of inflammatory cells into various parts of the gastrointestinal tract.

IBS, or irritable bowel syndrome is not the same thing as IBD (inflammatory bowel disease). IBS is occasional GI and intestinal inflammation or distress that’s more easily controlled with diet change and probiotics, and it’s rare in cats. IBD is chronic, and in some cases severe inflammation, that can spread to other areas of the GI tract and involve other organs, particularly the liver, pancreas and even kidneys. Due to the spread of inflammation, other problems may arise such as malabsorption of nutrients, poor digestion and scar-like fibrous tissue, SIBO (small bacterial overgrowth), EPI (exocrine pancreatic insufficiency), pancreatitis and liver disease.
See SIBO: https://ibdkitties.net/sibo/
See EPI: https://ibdkitties.net/pancreatitis/epi/

There is no cure for IBD and no definitive cause. In humans, although the underlying causes are not yet known, IBD has been definitively linked to “gut dysbiosis.” This means an imbalance between “unhealthy” and “healthy” bacteria, and the few studies so far in cats point to the same basic problem.
See Probiotics: https://ibdkitties.net/probiotics/

Management includes diet change, medications, traditional and holistic treatments (always under the care of a holistic vet). Symptoms can be varied and include vomiting, bad breath (halitosis), diarrhea, constipation, increased thirst from dehydration, gas, rumbling and gurgling in the stomach, abdominal pain, anorexia, moderate to severe weight loss, litter box refusal, dark/tarry stools, lethargy and depression, weakness and fatigue, vitamin deficiencies and anemia. Although many cats suffer from diarrhea as the main symptom, not all cats have to have diarrhea to be diagnosed with IBD. My Alex never had diarrhea with her disease.
See Alex’s case study: https://ibdkitties.net/case-studies-4/alex-p/

Inflammation can lead to other complications either from the disease or medication induced side effects. Unfortunately, there are occasions when there’s no way around that and the only choice is to treat the IBD or risk the disease progressing quickly, further complicating the recovery process. This is why it’s so important if you notice signs of ill health of any kind, such as those mentioned above, don’t procrastinate or hesitate. Get them seen by a vet well versed in IBD. When suspecting IBD or any gastrointestinal disease, it does not pay to wait. Early detection and treatment is paramount to stabilizing your pet and giving them a healthy, happy and long life. The sooner you get the inflammation under control, the better.

The GI tract acts as a second brain with a rich network of nerves and ganglia, communicating directly with the brain and the heart. Your digestive system also affects your moods through the hundreds of chemicals and hormones it produces, which is why some cats also suffer depression with this disease. There are literally trillions of microbes inside of all of us, human and animal. Altering the healthy bacteria that normally inhabit the GI tract can affect conditions ranging from IBD to asthma and allergies. The GI tract also has the largest amount of lymphatic tissue in the body with the lymphatic tissue being the main part of the immune system; which is why some cases of IBD can affect the lymph nodes and further stress the immune system itself.

Some Possible Causes:
Bacterial Overgrowth – Bacterial overgrowth as a result of overuse of antibiotics which in turn kills off all the healthy bacteria in the gut that’s meant to fight inflammation, parasites, etc.

Dental disease – This one is on me. There is no current information as to whether dental disease can contribute to IBD but I don’t see why not. Dental disease can cause major health issues like heart and kidney disease. As with humans, anytime there is inflammation in the gums that worsens and gets infected, it easily go into the blood stream. Inflammation spreads, there is no doubting that. If the inflammation begins in the mouth, it can easily spread to the GI tract, then to the intestines. Dental disease is not to be taken lightly in cats and can be extremely painful and take years off of their lives.

Environmental toxins – pesticides, mycotoxins, alfatoxins. Located in the outdoor environment, food and even cat litter.

Food allergies or intolerance – (protein allergies and/or grain allergies). Their immune system is overly sensitive to certain everyday substances and begins to identify them as dangerous.

Gut flora/bacteria – An inappropriate immune response to the natural flora in the intestines, or the result of a certain bacteria. The overuse of antibiotics are stripping their gut bare of good bacteria.

Gums/thickeners – Carrageenan is the big one. Scientific studies have shown that carrageenan can induce inflammatory bowel disease (IBD) in both humans and animals.
See Toxic/Unsafe Foods: https://ibdkitties.net/toxicunsafe-foods/

Infection – The intestinal tract harbors good bacteria and bad bacteria. If infection is chronic, the bad bacteria can take over and if this happens gradually enough, you may see a lymphocytic response to the resulting inflammation.

Over vaccination – Over-vaccinations can wreck havoc on their immune system and immune response and in turn cause the body to develop allergy responses.

Parasites – Parasites that cause the cat to produce antibodies which attacks its own digestive tract.

Poor Diet – Adding ingredients like grains, soy, starches, sugars, etc. Cats are obligate carnivores; always were, always will be. Adding a plethora of ingredients because it sounds good, does them NO good.

Stress – Stress can cause many changes in a person’s natural immune response and flora and it can do the same in a pet’s system. You’ll notice since they’ve developed IBD or inestinal issues, they get very easily stressed.

Testing and diagnosis:
There can be considerable costs between testing, diagnostics, food, treatments, medications and at times hospitalizations. But without intervention your cat cannot start to improve until it may be too late to stop the progression of the disease. Your cat is a valued family member and these treatments would be expensive even for a human. Proper tests consist of a blood panel, a biochemical profile, a complete T4 to check for hyperthyroidism, a urinalysis and fecal exam. Ultrasound can help identify IBD and is useful to rule out other medical conditions such as cancer. The most accurate way to diagnose IBD is through an open biopsy of the intestinal tract, where increased numbers of white cells called lymphocytes, eosinophils, and neutrophils may be seen in the intestinal wall. The types of cells present will provide a complete diagnosis of which type of IBD the cat has. An open biopsy is also the only sure way to differentiate between IBD and lymphoma (See IBD or cancer: https://ibdkitties.net/ibd-or-cancer/.

A biopsy can also be performed through an endoscope or via a needle guided by ultrasound, but since it is not full thickness it may miss a diagnosis of lymphoma and occasionally even IBD as IBD is an ever-changing condition. And biopsy itself is not always conclusive, which is what makes IBD so challenging to diagnose. It should first be discussed with your vet as to whether your pet’s condition warrants an immediate biopsy or if there could be complications from the operation. Occasionally there are underlying conditions that may affect your pet’s ability to undergo surgery, and other factors such as age.

Folate and B12 levels should always be checked. Low folate and/or B12 can indicate several things including SIBO (small bacterial overgrowth) and malabsorption syndrome. Additional tests may be warranted for secondary organ failure such as pancreatitis, liver enzymes and kidney levels. Please see the links on this site for information on those specific organs.

Treatments:
The first step is usually an elimination diet. Limiting their diet to one protein in order to find out if they have a food allergy/intolerance that is not IBD or is contributing to IBD. This can be a long process and if your kitty is very sick medications such as steroids, anti-nausea/anti-emetics, appetite stimulants, immunosupressants, antibiotics, fluids and B12 may be prescribed. It’s very important to understand that there is a time for trying holistic treatments and there is a time to go straight to the medications. If your kitty is in the beginning stages of IBD or over the hump of a bad flare, then seeing a holistic vet is a good idea and may in fact do the trick in terms of treatment. But if your kitty suddenly becomes very ill or continues to go downhill, it’s time to hit the medications. No one likes giving their pets meds but in times of crisis, you need to do what you need to do not only for their lives but their level of comfort. IBD can be painful and imagine if you threw up several times every day, or had explosive diarrhea several times a day, and you couldn’t stop it. Pain is pain and they experience it just as much as we do. The goal is to lesson their pain and give them quality of life over everything.

I am a big believer that both Western and Eastern medicine has a place in recovery from all diseases and health conditions. There can be side effects to using both as well as a lot of benefits. Feline IBD is not something to play around with and needs to be treated immediately. If your pet’s condition is deteriorating quickly and your vet feels that Western medications are warranted or things will continue to go downhill, I believe it’s necessary to do what you have to do in order to save your pet’s life. I’ve seen benefits from people who’ve brought their cats to two vets – one being a traditional vet and the other a holistic vet that works with their primary vet. When treating with all-natural remedies, be aware that natural doesn’t necessarily mean safe. Many natural remedies can be dangerous and even toxic to your pet. Try not to overload your pet with treatments as well. Your pet’s liver has to filter everything and too many treatments at once may unintentionally over-stress the liver. Never give your pet multivitamins without first asking your vet. Your pet’s food already has the proper and sufficient amount of vitamins and minerals.

Don’t buy into any miracle cures you may see on the web, or hear from other people (and there are many). IBD is manageable but NOT yet curable. IBD is a chronic disease; there are no magic pills, no magic diet or food, and no magic alternative treatments. That being said, feeding our cats as the obligate carnivores they are often helps by removing ingredients that contribute to GI stress and inflammation. And there are in fact many safe and effective treatments that stabilize your pet’s condition and greatly help in their recovery. Many all-natural products that are safe for human consumption may be too strong or not safe at all in high doses for pets. Your pet may have several health conditions where using certain treatments could worsen recovery. Always obtain all-natural products from a reputable source. Even if it may be cheaper to buy the human version, they could contain additives that are potentially harmful or damaging to your pet’s recovery. An exception to this is probiotic supplementation. In many studies human probiotic supplements administered to cats in the proper doses, have generally proven to be safer and higher quality in terms of meeting label claims of active strains. Make sure to always discuss alternative and all-natural therapies with your vet. And do the research yourself, look up the ingredients and make sure you KNOW it’s safe. Many pet product companies will state they are perfectly safe and that’s just not always true. We are seeing plenty of lawsuits these days in this regard and unfortuantely it means a pet has suffered dearly or even died. So please don’t chance it.

Look for a vet that’s open to knowledge and understands that experience from other pet owners is invaluable to treating these conditions. If you have a cats-only veterinarian in your area, it’s best to take your cat there. Their main focus in vet medicine is on cats and the diseases that affect them differently than other animals. In a dog, the bile duct and the pancreatic duct empty at separate locations in the GI tract. In the cat, they join and empty at the same place, making it more likely for inflammation to affect the various organs. An internist may also offer better treatment options if there’s one available in your area. Just remember in any case, to be as proactive as you can and learn as much about Feline IBD as possible.

References:
http://www.vcahospitals.com/main/pet-health-information/article/animal-health/endoscopy-gastrointestinal-in-cats/117
http://www.vcaspecialtyvets.com/arboretum-view/our-services/internal-medicine/colonoscopy
www.drhoffman.com
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845678/
http://healthypets.mercola.com/sites/healthypets/archive/2012/06/01/feline-ibd-symptoms.aspx
www.marvistavet.com/html/inflammatory_bowel_disease
www.merckvetmanual.com/mvm

Alcoholic Beverages – Ethanol is the component in alcoholic beverages that can be toxic when an excessive amount is ingested. Pets are much smaller than us and can be highly affected by small amounts of alcohol. Exercise caution when drinks and pets are together. Toxicity can cause a wide variety of signs, and may even cause death. Signs can include odor of alcohol on the animal’s breath, staggering, behavioral changes, excitement, depression, increased urination, slowed respiratory rate or cardiac arrest and death. Because a cat’s liver cannot filter alcohol prooperly I do not recommend using any kind of homeopathic treatment with alcohol as a base to stabilize it. This may cause toxic buildup in the cat’s liver. There are other options! Please see the supplements page.
http://www.petplace.com/article/cats/diseases-conditions-of-cats/features/dangerous-foods-are-they-harmful-to-your-cat
Alcohol in pet products is no better or safer than this. Alcohol is alcohol and though they may not get drunk on it, (grain, cane or ethanol alcohol), it’s still toxic as the buildup can and will damage the kidneys and liver.
http://www.natural-wonder-pets.com/how-harmful-is-alcohol-to-dogs-and-cats.html
http://www.natural-wonder-pets.com/dangers-of-alcoholic-dental-sprays-for-dogs-and-cats.html

Apples, Apricots, Cherries, Peaches and Plums – Ingestion of large amounts of stems, seeds and leaves of these fruits can be toxic. They contain a cyanide type compound and signs of toxicity include apprehension, dilated pupils, difficulty breathing, hyperventilation and shock.
http://www.petplace.com/article/cats/diseases-conditions-of-cats/features/dangerous-foods-are-they-harmful-to-your-cat

Avocados contain a toxic substance known as persin. Most parts of the avocado plant including the leaves, stems, fruits and pits may contain persin and damage the muscle of the heart and even your cat’s mammary glands. Symptoms of persin toxicity include congestion, vomiting, diarrhea, gastrointestinal distress, respiratory distress, possible fluid accumulation around the heart, and death. The meat and oils of specific kinds of avocados however do not prove to be toxic or harmful. If you’re going to give your pets avocados it’s best to leave it to the types that are in pet food as they’ve been removed of all toxic elements and are in small quanities:
http://www.avodermnatural.com/About/avocados_bad_discussion.htm

Baking soda and Baking Powder are both leavening agents, a common ingredient in baked goods that produces a gas causing batter and dough to rise. Baking soda is simply sodium bicarbonate. Baking powder actually consists of baking soda and an acid, usually cream of tartar, calcium acid phosphate, sodium aluminum sulfate or a mixture of the three. Ingestion of large amounts of baking soda or baking powder can lead to electrolyte abnormalities (low potassium, low calcium and/or high sodium), congestive heart failure or muscle spasms. If you cat should accidentally ingest some baking soda it’s not cause for alarm and will most likely not harm them.
http://www.petplace.com/article/cats/diseases-conditions-of-cats/features/dangerous-foods-are-they-harmful-to-your-cat
http://pets.thenest.com/can-baking-soda-hurt-cats-10555.html

Broccoli contains isothiocyanate (mustard oils), and in large amounts can cause severe gastrointestinal upset. In extremely large amounts (25% of the diet) it can be fatal. Small amounts of broccoli given in pet food are fine.
http://pets.thenest.com/broccoli-sprouts-safe-cats-10206.html

While these studies are on human products I wouldn’t chance it with pet food as well as dangerously high levels of arsenic were found in multiple sources including baby food.
Brown rice and arsenic
www.wjla.com/articles/2012/02/brown-rice-may-contain-toxic-arsenic-levels-study-shows–72683.html
Reported in Juice, Now in Rice; Arsenic is Everywhere
www.foodsafetynews.com/2011/12/first-reported-in-juice-now-in-rice-arsenic-is-everywhere/?
utm_source=newsletter&utm_medium=email&utm_campaign=111209
Arsenic and Rice. Yes, again
White rice has less toxic levels than brown rice due to the hulls being removed
www.wired.com/wiredscience/2012/09/arsenic-and-rice-yes-again/

Carrageenan – Used as a thickening and stabilizing agent in foods, carrageenans are highly flexible molucules produced by different types of seaweed. The thickness of the agent depends on which seaweed is used to make the finished product. Scientific studies have shown that carrageenan can induce inflammatory bowel disease (IBD) in both humans and animals. Unfortunately carrageenan is used in just about every commercial pet food available. But there are many now who are removing it. Please check ingredients when buying pet food.
http://www.ncbi.nlm.nih.gov/pubmed/2073092
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242073/

http://www.cornucopia.org/2013/12/carrageenan-risks-reality
http://www.cornucopia.org/wp-content/uploads/2013/02/Carrageenan-Report1.pdf
http://www.cornucopia.org/2016/04/report-exposes-food-industry-cover/?utm_source=eNews&utm_medium=email&utm_content=4.23.16&utm_campaign=CarraMORE

Citrus fruits and oils of any kind can cause severe vomiting and GI distress. d-Limonene and linalool are citrus oils with insecticidal properties. These are metabolized in the liver resulting in liver damage or failure. If ingested, citrus oils and any essential oils in full strength form, can cause liver or kidney failure. If they’re inhaled they can even cause neurological disorders and brain damage. Cats are more susceptible than dogs. If the product also contains piperonyl butoxide, the toxic effects of citrus oil extracts may be increased. Never treat your cats with dog products, the result may be fatal.

https://books.google.com/books?id=BLkPFlB15v0C&pg=PA513&lpg=PA513&dq=citrus+fruits+and+oils+toxic+to+cats&source=bl&ots=TvduQWGNKi&sig=Eglko6zCikLR4ZJlJd-aiWeTiyg&hl=en&sa=X&ved=0ahUKEwievt6v4s_JAhXC6x4KHd24DDQ4ChDoAQgiMAI#v=onepage&q=citrus%20fruits%20and%20oils%20toxic%20to%20cats&f=false

Chocolate/Caffeine – Theobromine and caffeine are the ingredients in chocolate that contribute to the side effect in pets. The combination of these two ingredients can cause problems like vomiting and diarrhea, or severe and potentially fatal effects like heart arrhythmias or cardiac and respiratory arrest. It’s advised that the darker the chocolate is, the more harmful it is to pets. Cocoa powder and baker’s chocolate are the most dangerous, milk and white chocolate have the least amount of theobromine, and dark chocolate and semi-sweet chocolate lie somewhere in the middle. As a safety measure, it should not be given to your cat or any pet under any circumstances. Caffeine in large enough quantities can be fatal for a cat. And there is no antidote. Symptoms of caffeine poisoning include restlessness, rapid breathing, heart palpitations, muscle tremors, and fits. In addition to tea and coffee — including beans and grounds — caffeine can be found in cocoa, chocolate, colas, and stimulant drinks such as Red Bull. It’s also in some cold medicines and painkillers.
http://www.petplace.com/article/cats/diseases-conditions-of-cats/features/dangerous-foods-are-they-harmful-to-your-cat
http://pets.webmd.com/cats/ss/slideshow-foods-your-cat-should-never-eat

Cooked Bones from fish, poultry, or other meat sources can cause obstruction or laceration of the digestive system if the pieces are too large. For cats, a chicken neck or wing bone fed raw is safe and even encouraged by some raw food advocates. Cooking bones greatly reduces their benefits and poses many dangers rendering the natural calcium almost unavailable for absorption. Cooked bones are much tougher and more brittle than raw bones, and will actually blunt an animals teeth after regular chewing. They also break into large chunks more easily, and your pet may swallow a piece too large to digest. Cooked bones are very slow to breakdown in the animals gut and can cause severe gut pain (colic), scarring of the gut lining and bleeding, which can lead to constipation.
http://www.cat-world.com.au/human-foods-which-are-poisonous-to-cats

Dog Food if a cat eats dog food accidentally once or twice it shouldn’t be a problem, but if fed repeatedly it can result in malnutrition and diseases affecting the heart. Cats need taurine, vitamin A and higher levels of protein.
http://www.petmd.com/blogs/dailyvet/2009/August/21-4582
http://pets.thenest.com/dangerous-cats-eat-dog-food-4228.html

Fruit pits and cores contain trace amounts of cyanide that are naturally derived from nature. They aren’t toxic to humans in these small amounts but they are toxic to pets.
https://www.petcarerx.com/article/poisonous-foods-for-cats-chocolate-yeast-alcohol-onions/249
http://www.cat-world.com.au/human-foods-which-are-poisonous-to-cats

Milk – Cats are unable to produce the enzyme lactase and can’t break down the lactose, or milk sugar in dairy products. They’re usually lactose-intolerant and the lactose in milk and milk products can cause stomach upset, cramps, gassiness, leading to diarrhea or vomiting.
http://www.cat-world.com.au/can-cats-drink-milk
http://pets.webmd.com/cats/guide/cats-and-dairy-get-the-facts

Mushrooms of any kind can contain toxins, can affect multiple systems in the body, cause shock and result in death. Depending on the type/species of mushroom ingested, several general organ systems can be affected.
http://pets.thenest.com/mushrooms-poisonous-cats-9179.html
http://www.petpoisonhelpline.com/poison/mushrooms/

Nuts of any kind are harmful but Walnuts and their hulls and Macadamia Nuts are especially toxic. Effects can be anything from vomiting and paralysis to death. Pets can start to develop symptoms such as an inability to stand or walk, vomiting, hyperthermia (elevated body temperature), weakness, and an elevated heart rate within 12 hours of eating nuts. Nuts of any kind are high in fat and can cause inflammation of the pancreas (pancreatitis) and their high phosphorous levels can possibly lead to bladder stones. Walnuts and most nuts can develop a fungus called alfatoxin. It can cause gastrointestinal problems such as vomiting and diarrhea, as well as respiratory issues such as sneezing, breathing and coughing. Aflatoxins – a naturally occurring fungus on grains and legumes – is a carcinogenic fungus. Avoid all animal-feed grade nuts.

http://ottawavalleydogwhisperer.blogspot.com/2012/02/foods-that-dogs-should-never-eat.html

Onions, Garlic, Chives & Related Root Vegetables (raw, cooked or powdered): Onions contain a
substance known as N-propyl disulphide, that deform red blood cells in many species of animals and can cause the cells to burst. These changes in red cells can lead to jaundice, anemia, weakness or collapse, as well as kidney and liver dysfunction.
http://www.petinsurance.com/healthzone/pet-articles/pet-health-toxins/Pets-and-Onions.aspx
http://pets.thenest.com/onion-toxicity-level-cats-8684.html
http://pets.thenest.com/chives-poisonous-cats-9449.html

Pork as a whole is fine but avoid any Pork products, especially bacon, which contain the hazardous preservative, sodium nitrate.
http://www.ncbi.nlm.nih.gov/pubmed/16031985

Raisins and Grapes can cause kidney failure in some dogs, but not all dogs are susceptible to the toxic effects of these foods. Some dogs have died after eating a few grapes while it doesn’t seem to bother others. There have only been occasional reports of cats developing problems after eating raisins and it’s not yet known why the fruits may be toxic. It’s unknown if it is a mycotoxin (produced by a fungus), pesticide, heavy metal, or a yet-unidentified toxin.

Raw Eggs whites contain an enzyme called avidin, that decreases the absorption of biotin (a B vitamin) and can lead to skin and hair coat problems. Cooking the egg whites neutralizes the avidin, therefore raw egg yolks are safe to feed when feeding a raw diet, whereas raw egg whites are not.
http://pets.thenest.com/raw-egg-whites-good-cats-dogs-6763.html

Feeding Raw Fish can result in a thiamine (B1 vitamin) deficiency leading to loss of appetite, seizures, and in severe cases, death. Raw fish contains an enzyme called thiaminase, which can destroy vitamin B1. This enzyme can be destroyed by cooking the food.
http://www.vetstreet.com/our-pet-experts/7-foods-you-should-never-feed-your-cat

Rhubarb leaves contain oxalates. Eating rhubarb leaves leads to oxalic acid poisoning which can cause kidney failure. The cooked rhubarb stem is safe to eat, but is very high fibre and may cause indigestion, intestinal discomfort and diarrhea.
http://www.petpoisonhelpline.com/poison/rhubarb/
https://www.aspca.org/pet-care/animal-poison-control/toxic-and-non-toxic-plants/rhubarb

If Salt is eaten in large quantities it may lead to electrolyte imbalances.
http://www.petpoisonhelpline.com/poison/salt/
https://www.petcarerx.com/article/poisonous-foods-for-cats-chocolate-yeast-alcohol-onions/249

Soy is found in various forms in many products and acts as a hormone. It contains compounds called phytoestrogens that may negatively affect cats by interfering with nutrient absorption, normal growth, thyroid function, and hormonal development. Hyperthyroidism is extremely common in cats so soy should not be in cat food even in small amounts. Unfortunately, soy is a common ingredient used by pet food manufacturers.
http://healthypets.mercola.com/sites/healthypets/archive/2012/03/28/avoid-using-soy-on-pets.aspx
http://drjeandoddspethealthresource.tumblr.com/post/42291453086/soy-exposing-popular-pet-food-protein#.Vq7TV9CmzYg

Spinach does not belong in pet food! Spinach has one of the highest calcium oxalate levels of any food. Cooking does NOT diminish the oxalates much at all, very minimally. The oxalates in spinach are very sturdy, binding and are around 600-750 content milligrams per 100 gram serving. You’d have to boil or blanch it to reduce it even 5-15% and then you’ve lost all the nutrients in it. 1/2 a cup of cooked spinach contains 755 mgs of oxalates and 1 cup of raw spinach contains 656 mgs. Because spinach is now being added in a lot of pet food brands, you may want to make sure to feed other foods and rotate that food so it’s not fed every day. Or if your cat suffers from kidney, gallbladder or thyroid issues, you should forgo feeding it to them altogether! They should not be eating any foods with those levels as it can do severe damage. Spinach can cause crystal formation in the urinary tract and kidneys in cats. Calcium oxalate stones are EXTREMELY painful and once formed in the kidneys, cannot be removed. Whether cooked or raw, spinach should be completely avoided in cats and has been shown to cause such major damage it can result in hospitalization and in some circumstances, death. I personally know someone who’s cat died from being fed raw spinach. I recommend writing to the pet food companies that do include spinach and request that they remove it completely from their products. NEVER feed raw spinach to your pet, whether they are ill or healthy!

It’s also not good for cats or people with any kind of bowel disease due to acidic urine: In bowel disease, fatty acids and bile that are normally absorbed by the small intestine reach the colon. When fatty acids and bile reach the colon, they can damage the colon lining allowing oxalates to pass through the damaged lining into the blood, and then into the urine via the kidneys. When calcium and oxalates are together in the kidney, they can bind together to form crystals. These crystals can join together to form calcium oxalate kidney stones.
http://www.litholink.com/downloads/stone_lowoxalatediet.pdf
http://www.petmd.com/cat/emergency/poisoning-toxicity/e_ct_outdoor_plant_poisoning#.UlSCGVCsidk
http://www.cathelp-online.com/emergency/hazards.php
http://www.webmd.com/kidney-stones/tc/foods-high-in-oxylate-topic-overview
http://oxvox.com/cooking-food-does-not-lower-oxalate-levels/
http://www.whfoods.com/genpage.php?tname=faq&dbid=23

Spoiled Food, Mold and Bacteria: Spoiled foods and molds that grow on food harbor harmful bacteria and may also contain toxins. Unless starving, cats will generally avoid stale or spoiled foods. If they do ingest it, their first line of defense is to vomit it back up again. If the food smells or looks bad to you, throw it out. Don’t feed it to your cat or yourself. (I really don’t think I need to include a link for this one, I’d hope people would have common sense to know this is true).

Sweeteners: Sorbitol falls within the same chemical category as the sweeteners xylitol and mannitol. Because it’s especially hard for them to digest, large amounts of sorbitol can affect pets in an adverse way. Sorbitol is used in a multitude of pet foods for moisture retention, is less vulnerable to mold and may be bacteria resistant. It is also used as a plastic making agent. Sorbitol and mannitol for a pet can lead to severe diarrhea, GI irritation and malabsorption issues. Although not toxic like xylitol, sorbitol used in anything other than pet food may be best avoided, especially with cats already experiencing GI upset like an IBD kitty, or one with a compromised immune system. Most pet toothpaste brands contain up to 50% sorbitol and states clearly on their literature that it can give them very bad stomach upset and diarrhea; which is what happened to my cats.

Other names for sweeteners and sweetening agents include dextrose, maltodextrin, fructose, sucrose, high fructose corn syrup, corn syrup, etc. The list is lengthy and when buying any product for your kitty including supplements, check the label for these products and stay away from them. This article is from a science magazine website and explains why cats shouldn’t consume anything sweet. Very informative on the inner workings of the cat’s digestive tract in regards to sweets of any kind:
http://ottawavalleydogwhisperer.blogspot.com/2012/05/ingredients-in-dog-toothpaste-oral.html
http://pets.thenest.com/cats-sorbitol-11950.html

Tomatoes are members of the solanaceae family of plants and are related to deadly nightshade. They contain a bitter, poisonous alkaloid called glycoalkaloid solanine that can cause violent lower gastrointestinal symptoms. Cooking will destroy that toxin. Green tomatoes, the leaves and stems of the green and red tomatoes are all toxic.
http://www.petpoisonhelpline.com/poison/tomato-plant/
http://cats.about.com/cs/catfood/a/humanfood.htm

Like tomatoes, Potatoes are members of the solanaceae family of plants and are also related to deadly nightshade. They also contain glycoalkaloid solanine and any uncooked or green potatoes and potato peelings are all toxic. Once cooked, the alkaloid is destroyed making the potato safe.

Tuna if fed in excess, can lead to steatitis (yellow fat disease, pansteatitis). Tuna flavoured cat foods are not the cause of this condition, feeding your cat human tuna is the cause. This painful inflammatory condition results from a diet high in unsaturated fatty acids, over-consumption of oily fish and a Vitamin E deficiency. Tuna is very addictive to cats, but contains little vitamin E and the excessive unsaturated fatty acids further deplete vitamin E in the body. Cats with steatitis develop flaky skin and a greasy, dull coat, show signs of severe pain when touched and are reluctant to move. They also lose their appetites and develop fever. If untreated, it results in death. Besides pansteatitis, feeding human grade tuna to your cat risks giving them mercury poisoning and other harmful toxins. Cats’ livers are especially sensitive and cannot process these metals like humans can. There is also new research pointing to a diet high in fish causing thyroid disease in cats:
http://www.petmd.com/cat/emergency/poisoning-toxicity/e_ct_human_food_poisoning
http://www.secondchancecats.org/steatites.php
http://www.acs.org/content/acs/en/pressroom/presspacs/2016/acs-presspac-january-6-2016/fish-flavored-cat-food-could-contribue-to-feline-hyperthyroidism.html
http://phys.org/news/2016-01-fish-flavored-cat-food-contribute-feline.html

Yeast/Bread Dough – Bread dough can quickly expand in a cat’s stomach, causing it to swell beyond its capacity, cutting off its blood supply. The expanding dough can produce gas in the digestive system, causing pain and possible rupture of the stomach or intestines. Also, ethanol produced by the fermenting yeast is absorbed into the blood stream causing effects such as being uncoordinated and disorientation. Brewer’s yeast and dried yeast can cause a whole host of other problems such as allergies, skin conditions, GI irritation, etc.
http://pets.webmd.com/cats/ss/slideshow-foods-your-cat-should-never-eat#

Xylitol, a common sweetener found in some diet products, chewing gum, candy, etc., may cause a sudden drop in an animal’s blood sugar, loss of coordination and seizures. Xylitol has been linked to liver failure in dogs and death within hours of ingestion. According to the American Society for the Prevention of Cruelty to Animals, xylitol is toxic to animals. In cats it can prompt a sudden release of insulin, resulting in low blood sugar, a condition known as hypoglycemia. Signs that your cat may have swallowed a product containing xylitol include a sudden lack of coordination, vomiting, lethargy and, eventually, seizures and possibly coma. Ultimately a cat that eats xylitol may end up with liver failure, resulting in death.
http://pets.thenest.com/xylitol-harmful-cats-4576.html

Toxic and Non-Toxic Plant List – Cats
www.aspca.org/Pet-care/poison-control/plant-list-cats

Plants toxic to cats
http://user.xmission.com/~emailbox/plants.htm

Here is a great youtube video from the ASPCA that tells you about poisonous plants.
www.youtube.com/watch?v=WndJLJD8R9k.

By Cheryl Craig

TREATING IBD AND CRF
If you have found your way to this website, you probably already have some idea of how difficult it can be to care for an IBD kitty. When there are other medical conditions as well, it can seem especially overwhelming, as there may be conflicting treatments, diets and advice coming from all directions. Since our bodies are designed to work synergistically it makes sense that when one organ or body part is diseased and not functioning properly, other organs may be affected.  Chronic Kidney Disease (CKD) is a very common disease in cats, and like IBD there is no cure at the present time. However with early detection and proper treatment many cats can enjoy a good quality of life for many years.

WHAT EXACTLY IS CHRONIC KIDNEY DISEASE
Chronic Kidney Disease (CKD), also known as Chronic Renal Failure (CRF), is a gradual and irreversible deterioration of the kidneys. Most older cats have some degree of CKD, and certain breeds are more susceptible. The kidneys are made up of thousands of microscopic nephrons which serve to filter and reabsorb fluids. In young healthy cats there is such a surplus of nephrons that some are held in reserve. As the cat ages or has damage to the kidneys, some nephrons stop working and the ones in reserve take their place. When all the nephrons in reserve are depleted, signs of kidney disease will begin to appear. It is because of this reserve system that indicators of kidney disease do not show up until there is significant loss of kidney function. At that point, the kidneys are unable to conserve water, and significant amounts of dilute urine are passed.

Because the filtraton system is no longer working the way it should, toxins build up in the system. The kidneys also regulate the amount of water in the blood and maintain a healthy blood pressure by regulating sodium levels. Calcium and vitamin D are also regulated by the kidneys. In addition, the kidneys also secrete a hormone called erythropoieton which stimulates the bone marrow to produce red blood cells. With so many functions performed by the kidneys, symptoms can vary widely between cats and progress slowly or come on quite suddenly. It also means that kidney disease carries the potential of other related diseases including hypertension, anemia, diabetes and hyperthyroidism.

WHAT CAUSES KIDNEY DISEASE
It is rare that an exact cause of CKD is found. It can be congenital at birth, chronic bacterial infections of the kidneys or urinary obstructions, exposure to toxins, immune system disorders, and certain drugs, such as NSAIDS and some antibiotics. A steady diet of dry and over processed low quality protein puts an additional load on the kidneys. This does not happen overnight, but has a cumulative effect that is not apparent until significant damage has been done.

DIAGNOSIS
IBD is a difficult disease to diagnose, and is only definitive with a surgical biopsy. Many choose not to take this route when a kitty is already very ill and weak to begin with, so a diagnosis is made based on symptoms, other diagnostics and ruling out other possible issues. With CKD a proper diagnosis can be made with a full blood panel and urinalysis, but usually not until 66% of kidney function has been lost. There is, however, a new test, SDMA, that may help detect a problem earlier. https://www.idexx.com/files/small-animal-health/solutions/articles/intro-kidney-test-sdma.pdf.

So a large part of early detection of CKD falls on the pet parent in getting regular blood work done (especially in older kitties), and monitoring the water bowl and litter box. If you have an IBD kitty, you are probably already spending more time than you ever imagined peering in the litterbox. Copious amounts of urine can be a clue. As can excessive drinking, although steroids can also cause increased thirst too. Nausea and inappetance can be a sign, but that can also be caused by IBD. So getting regular blood work is really the best way to determine if something else is going on. There can be dramatic changes in as little as six months. With CKD, a urinalysis is also important. Early indicators may require additional testing.

CKD is usually staged according to the IRIS system from 1-4, with stage one being the earliest stage. But don’t despair. Blood work in the earliest stages can be influenced by dehydration and other factors that often make things look worse than they are. And many kitties can do surprisingly well with as little as 10% kidney function with proper treatment. As always, treat the cat, not the numbers.

Another issue that is common to both IBD and CKD are the formation of kidney stones. Kidney stones can form as a result of minerals (generally calcium and oxalate) binding in the kidneys. Urine that is too acidic is more likely to cause these stones to form. Cats with bowel disease and malabsorbtion issues as well as cats with kidney disease tend to have more acidic urine. Foods labeled “for urinary tract health” ironically tend to acidify the urine and should be avoided, as well as anything containing cranberry. Foods containing high oxalate ingredients including spinach, chard, soy and cereals can add to the risk of stone formation. Sometimes a vitamin B6 deficiency can cause the problem. Often kidney stones are left untreated if they are small and inactive, but should be monitored regularly. Signs may include blood in the urine or frequent kidney infections. If your kitty stops urinating or exhibits signs of straining or discomfort, it is time to go straight to the vet, as a blockage is a medical emergency and must be treated immediately. http://www.litholink.com/downloads/stone_lowoxalatediet.pdf

If it is confirmed that your kitty has kidney disease as well as IBD, then what’s next? Well, the good news is that there are many similar issues and treatments, so you may well already have a few of these things under your belt. So take a deep breath. You can do this! Here is a list of low phosphorous foods: http://www.felinecrf.org/canned_food_usa.htm

HYDRATION
This is a crucial treatment in managing CKD, and many IBD kitties as well. Cats with CKD become dehydrated because their kidneys are not able to conserve water. They tend to drink a lot and urinate a lot. Despite that, their kidneys are also having a hard time filtering toxins and can benefit from help flushing them out. IBD kitties are prone to diarrhea and/or vomiting which can also lead to dehydration. Adding a couple of tablespoons of water to their food,  feeding home made broth (without onions, garlic or salt), and if necessary giving Sub Q fluids can help your kitty feel much better, and help prevent the progression of the disease. Dry foods are dehydrating, so avoid them unless it is the only thing your cat will eat.

NUTRITION
This may be the single most important treatment in both IBD and CKD kitties. IBD kitties may have sensitivities to certain proteins or ingredients in commercial cat foods such as thickeners and gums. The “old school” thinking (which many vets still preach) is that CKD cats need a low protein, low phosphorous diet. New research is questioning whether a low protein diet does any good in preventing further kidney damage, and that it may even do more damage in causing muscle wasting since cats rely heavily on protein for their health. http://www.felinecrf.org/nutritional_requirements.htm

The issue is more about providing good quality (human grade) easily digestible protein, which is not easily found in commercial foods. The culprit is phosphorous, which is in all meat, but can be reduced by limiting bone and using some egg whites as a protein source and eggshell as a calcium source. https://ibdkitties.net/tips-tricks/ Tip #3: Cats with CKD often do very well on raw diets without bone, and home cooked human grade food with proper supplementation and eggshell as the calcium source. The same can be said for IBD kitties and the advantage is that you can use whatever protein source your cat can tolerate and eliminate possible irritants in commercial foods. If that is not possible, aim for commercial canned foods with high quality protein, as few additives as possible and lower phosphorous.  If your kitty will not tolerate low phosphorous foods, a binder can be added, such as Epakitin or Aluminum Hydroxide. If your cat’s phosphorous level is 6 mg. or higher, you need to use a binder http://www.felinecrf.org/phosphorus.htm.

MEDICATIONS
One of the biggest challenges of both IBD and CKD kitties are the plethora of medications that are sometimes needed to maintain their health and a good quality of life. Many of these are the same for both, but there a few additional cautions with CKD cats, since many medications are processed through the kidneys and can cause problems, since CKD cats suffer from a build up of toxins in their systems to begin with. Nausea is a common problem in both IBD and CKD kitties. In CKD kitties, stomach acid is frequently the culprit. Sometimes feeding smaller and more frequent meals can be enough to help. Slippery Elm Bark Syrup is effective and has the added advantage of adding fiber and helping to regulate the stools and help prevent hairballs. https://ibdkitties.net/tips-tricks/ (Natural Remedies #1). Pepcid AC or generic famotidine can be used (1/4 of a 10 mg. tablet) given 30 minutes before feeding can usually solve the problem. If vomiting is more of a problem, Cerenia works well for both IBD and CKD kitties. Miralax can be used for constipation if Slippery Elm Bark or pumpkin doesn’t help. A probiotic called S. Boulardi is often effective for diarrhea. https://ibdkitties.net/probiotics/ See “emergency stop diarrhea” instructions. Other cautions for CKD cats regarding antibiotics and painkillers can be found here. http://www.felinecrf.org/treatments_antibiotics_painkillers.htm Please check with your vet before using any medications, even if they are available without prescriptions.

SUPPLEMENTS
Most cats with IBD and/or CRF can benefit from a vitamin B12 supplement, given by injection under the skin. It will help with nutrient absorption and can increase appetite.  These can be done at home, limiting stress to your kitty and reducing costs. Your vet can show you how to do it, and there are many videos on youtube that demonstrate it as well. Probiotics are essential for ANY cat, and there is promising research to show help in treating both IBD and CRF. http://www.ncbi.nlm.nih.gov/m/pubmed/24212182/?i=5&from=%2F26462363%2Frelated We recommend human grade probiotics that have higher potency and more strains. There is not enough research to target specific strains and the microbiome is very complex, so the more strains the better. https://ibdkitties.net/probiotics/. Plant based digestive enzymes act as prebiotics and can help with the absorption of nutrients, which is helpful for both IBD and CRF. Omega 3 fatty acids are extremely beneficial to all kitties, and research continues to support the benefits for both IBD and CKD kitties. These are the basics, but there are additional supplements for specific needs.

There is ongoing research relating to the importance of Omega 3 fatty acids in helping to manage CKD and many other diseases, in addition to helping skin and coat issues. Krill and sardine oil, or other purified oils are recommended.
http://www.cliniciansbrief.com/sites/default/files/attachments/Top%205_Therapeutic%20Uses%20of%20Omega-3%20Fatty%20Acids.pdf
http://www.ncbi.nlm.nih.gov/pubmed/16100367

DISEASES RELATED TO CKD
There are other issues that can occur with CKD that you should be aware of:

Hyperthyroid
High Blood Pressure
Diabetes
Heart Disease
Anemia
Mouth Sores
Potassium imbalances

This is not to alarm you, as they may never happen, but it’s always a good idea to have these checked with your vet.

IN CONCLUSION
Managing multiple health issues is challenging, but it can be done. The goal is to provide you and your kitty the most quality time together you can have. Once you have a diagnosis, be proactive in their care. Most vets have busy practices and various species, medical issues and drug information to keep up with. You only need to be concerned with your beloved pets and their specific needs. Do research and work with your vet. Keep a journal or log of medications, responses, behaviors, etc. It’s easy to forget when you are dealing with multiple pets, health issues and medications and the more accurate you are the better your vet can help. He/she only sees your kitty for a limited amount of time, so you have to provide the info you observe in their daily routines. Ask questions and know we are here to help and support. We’re all in this together!

Other References:
http://healthypets.mercola.com/sites/healthypets/archive/2012/08/06/kidney-disease-in-cats.aspx

The Problems with Pepcid and other antacids, Part 1
By Laurie Goldstein, September 2015

One of the most common health-related medicinal recommendations I see for cats experiencing gastrointestinal issues such as nausea, inappetence, and “overnight bile pukes” is Pepcid a/c (famotidine). And why not? It is perceived to be very safe, many vets recommend it, and antacids generally are easy to obtain all around the world. Call the vet first! They’ll probably say it’s OK to give it a try, and it often does (seem to) help. This is because acid suppression can address the symptoms and our uncomfortable kitties feel better and begin to eat or stop throwing up. Sometimes just stopping the cycle of nausea and inappetence for a couple of days is enough to turn the tide when your cat is feeling poorly. Short-term, occasional or intermittent use of antacids is not the issue.

Long-term use is.

Note: The manufacturers of the over-the-counter antacids do not recommend use longer than two weeks at a time without consulting a physician, and Prilosec (omeprazole) is not intended for more than two weeks of use every four months. Our vets and our doctors often fail to mention this.

So what are the problems?
Because we are led to believe they are completely safe, many cats are given antacids frequently, regularly, and have been on antacids long term to soothe upset tummies. And we may unintentionally and unknowingly be contributing to our kitties’ illness.

How are antacids making some cats sick?

The gastrointestinal tract is technically outside of the body. It is a giant hole, a passageway that snakes from mouth to anus filled with barriers to prevent unintentional movement from “outside” to “inside.” It is segmented with a system of valves to prevent “backflow” and isolate contents of one section from another until an appropriate time. Its purpose is not only to process nutrients we ingest, but to prevent infection from bacteria, viruses, parasites, and all the many toxins to which we are exposed. By its very nature, the GI system must account for the bulk of our immune system defense. Estimates of that percentage range from 70% to 80%: either way, the health of the GI tract and maintaining those barriers in proper condition is absolutely critical to overall health. The low pH of stomach acid and the low average pH of the stomach contents is one of the very first lines of that defense system.

Problem 1: Taking medications that constantly neutralize or block stomach acid production interfere with the body’s normal immune defenses.

The higher-than-normal pH created by the antacids is associated with

– C difficile infection
– bacterial overgrowth
– small intestinal bacterial overgrowth (SIBO), and
– bile acid deconjugation, a common (and often undiagnosed) cause of chronic diarrhea and fat malabsorption.

Problem 2: Antacids interfere with nutrient absorption.

Have you ever prepared bone broth? Add a dash of apple cider vinegar (which is 5% – 7% acetic acid), and your broth softens the bones faster. Same principle here: stomach acid is needed to prepare vitamins and minerals for absorption, and has a critical role in B12 metabolism. With acid suppression, the pH of the stomach increases and the absorption of nutrients becomes impaired due to what is basically improper preparation. Decades of research show that low stomach acid (whether natural or induced by medication) reduces absorption of:

– Iron
– Calcium
– Zinc
– Folate (Vitamin B9, Folic Acid)
– B12 (Vitamin B12, Cobalamin)
– Vitamin D

Problem 3: Motility and muscle tone.

The higher pH of the stomach artificially created by antacids results in delayed gastric emptying times (gastroparesis). This can cause

– Further increased stomach pH
– upper abdominal pain
– loss of appetite
– changes in blood sugar levels
– feeling full after eating only a little bit.

It has also been demonstrated that the cascade of chemical impacts from the higher-than-normal gastric pH can cause an abnormally relaxed ileocecal valve, leading to translocation of bacteria from the large intestine into the small intestine, which enables SIBO (see above).

Problem 4: Chronic Kidney Disease (CKD)/Chronic Renal Failure (CRF) and aging kitty antacid toxicity

Antacids can become toxic if not used at reduced levels and/or reduced intervals in cats with kidney disease or in kidney failure due to slower renal clearance and longer drug half-life. The same is true in older cats due to altered physiology (water/fat/muscle mass changes due to age) that results in higher blood plasma concentrations. In fact, the manufacturers of antacids specifically recommend lower doses for humans with impaired renal function – yet as in people, these cautions are often overlooked in caring for our cats.

Other Antacids
There are two primary classes of acid suppressing medications:

1) H2 Blockers (H2 antagonists): Pepcid a/c (famotidine); Zantac (ranitidine); Tagamet (cimetidine)
2) Proton Pump Inhibitors (PPIs): Prilosec (omeprazole), Nexium (esomeprazole), Protonix (pantoprazole), and Prevacid (lansoprazole).

The H2 blockers like Pepcid are not the worst offenders when it comes to acid suppression, and all of the H2 blockers are available over-the-counter (at pharmacies without a prescription). Although the risks are generally the same for both classes of acid suppressants (and the risk of toxicity the same for kidney disease or renal failure), the probability of experiencing these unhealthy and unwanted side-effects are greater with the proton pump inhibitors like Prilosec (omeprazole) (see references).

PPIs inhibit acid secretion more effectively than H2 blockers which is why they are carry a higher risk of any or all of these associated problems. Omeprazole (Prilosec) is the only one of the PPIs sold at pharmacies without a prescription, and dosages for cats can (unfortunately) easily be found online.

These studies are in humans – why does this matter to my cat?
The basic chemical and neurological signaling mechanisms in the gastrointestinal tract are similar in cats and humans. This is why antacids designed for humans work to suppress stomach acid in cats and why we use them in the first place. Although there are no studies of the impact of acid suppressants in cats, the naturally low gastric pH is potentially more important for our obligate carnivores – especially if fed a fresh, species-appropriate food:

– Gastric pH acts as an ecological filter, preventing harmful bacterial infection and protecting the healthy balance of bacteria needed to support nutrient metabolism and overall health.
– Gastric pH impacts motility, and normal intestinal motility is a major defense mechanism against attachment of pathogenic bacteria in the small intestine.
– Low gastric pH is essential for cleaving B12 from the amino acids in meat;
The low gastric pH is needed to properly metabolize minerals (let alone derive those minerals from bone).

This is why we need to approach Pepcid a/c (famotidine), Zantac (ranitidine) and PPIs like Prilosec (omeprazole) with caution. There is a place for these drugs in the short term care of cats in gastric distress, no doubt. But ultimately the solution is to understand and cure or mitigate the underlying problem, rather than continue to mask it with a remedy that might be making your cat sicker in the long term.

I know – those of you who have cats with kidney disease are saying, “But there is no cure.” In Part 2, we share research that indicates most cats with kidney disease (unlike dogs and humans with CKD or CRF) suffer a nausea that is related to uremic toxins, not excess gastric acid, and is best treated centrally, not with antacids.

If my cat hasn’t been diagnosed with GERD, what are my treatment options? In Parts 2 and 3 we will discuss alternatives to antacid medications for managing kitty’s nausea and vomiting.

References

Ahn JS et al 2013. Acid suppressive drugs and gastric cancer: a meta-analysis of observational studies, World J Gastroenterol Apr 28:19(16):2560-8 (2013). http://www.ncbi.nlm.nih.gov/pubmed/23674860

Beasley et al 2015. The Evolution of Stomach Acidity and Its Relevance to the Human Microbiome, PLoS ONE 10(7): e0134116. doi:10.1371/journal.pone.0134116 (2015). http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0134116

Carter D et al 2013. Prevalence and predictive factors for gastrointestinal pathology in young men evaluated for iron deficiency anemia, May: 58(5):1299-305 (2013). http://www.ncbi.nlm.nih.gov/pubmed/23192647

Cheungpastiporn W et al 2015. Proton pump inhibitors linked to hypomagnesemia: a system review and meta-analysis of observational studies, Aug: 37(7):1237-41 (2015). http://www.ncbi.nlm.nih.gov/pubmed/26108134

Dukowicz AC et al 2007. Small Intestinal Bacterial Overgrowth: A comprehensive review, Gastroenterol Hepatol (NY), Feb: 3(2):112-122 (2007). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/

Gallieni M & Cancarini G 2015. Drugs in the Elderly with Chronic Kidney Disease, Nephrol Dial Transplant, 30(3):342-344 (2015). http://www.medscape.com/viewarticle/842049

Islam RS and DiBaise JK 2012. Bile Acids: Nutrition Issues in Gastroenterology, Series #110, Practical Gastroenterology (October 2012). http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/Parrish_Oct_12.pdf

Jameson R et al 2013. Proton Pump Inhibitor and Histamine 2 Receptor Antagonist Use and Vitamin B12 Deficiency, JAMA 310(22):2435-2442 (2013). http://jama.jamanetwork.com/article.aspx?articleid=1788456

Lo WK and Chan WW 2013. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: a meta-analysis, Clin Gastroenterol Hepatol May: 11(5):483-90 (2013). https://www.ncbi.nlm.nih.gov/pubmed/23270866

Lombardo L 2010. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy, Clin Gastroenterol Hepatol Jun: 8(6): 504-8 (2010). http://www.ncbi.nlm.nih.gov/pubmed/20060064

Manlucu et al 2005. Dose-reducing H2 receptor antagonists in the presence of low glomerular filtration rate: a systematic review of the evidence, Nephrol Dial Transplant, Nov:20(11):2376-2384 (2005). http://ndt.oxfordjournals.org/content/20/11/2376.full

Mora JR and von Andrian UH 2009. Role of retinoic acid in the imprinting of gut-homing IgA-secreting cells, Seminars in Immunology 21:28-35 (2009). http://vonandrian.hms.harvard.edu/Publications/2009/Mora_2009.pdf

Marcuard SP et al 1994. Omeprazole Therapy Causes Malabsorption of Cyanocobalamin (Vitamin B12), Annals of Internal Medicine, Vol 120, No. 3 (Feb 1994). http://annals.org/article.aspx?articleid=707082

Parkman HP et al 1998. Effect of gastric acid suppressants on human gastric motility, Gut 42:243-250 (1998). http://m.gut.bmj.com/content/42/2/243.full

PennState-Hershey, Milton S. Hershey Medical Center. Ulcer Medications – histamine H2 antagonists. http://pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000219

Roulet L et al 2012. Adverse effects of proton pump inhibitors: should we worry about long term exposure? Rev Med Interne Aug: 33(8):439-45 (2012). http://www.ncbi.nlm.nih.gov/pubmed/22284952

Russell RM et al 1988. Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid, J Lab Clin Med Oct: 112(4):458-63 (1988). http://www.ncbi.nlm.nih.gov/pubmed/2902178

Shindo K & Fukumura M 1995. Effect of H2-receptor antagonists on bile acid metabolism, J Investig Med, Apr: 43(2)170-7 (1995). http://www.ncbi.nlm.nih.gov/pubmed/7735920

Thorens J et al 1996. Bacterial overgrowth during treatment with omeprazole compared with cimetidine: a prospective randomized double blind study, Gut 39:54-59 (1996). http://gut.bmj.com/content/39/1/54.full.pdf

Tleyjeh IM et al 2013. The Association between Histamine 2 Receptor Antagonist Use and Clostridium difficile Infection: A Systematic Review and Meta-analysis. PLoS ONE, 2013; 8 (3): e56498. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056498

Vadokas B et al 1997. Effects of gastrin-releasing peptide (GRP) on the mechanical activity of the human ileocaecal region in vitro, Neurogastroenterology & Motility Dec: 9(4):265-270 (1997). http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2982.1997.d01-59.x/abstract

Vighi et al 2008. Allergy and the gastrointestinal system, Clin Exp Immunol 153 (Suppl 1): 3-6 (2008 Sep). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515351/

Wilhelm SM et al 2013. Perils and pitfalls of long-term effects of proton pump inhibitors, Expert Rev Clin Pharmacol, Jul: 6(4):443-51 (2013). http://www.ncbi.nlm.nih.gov/pubmed/23927671

The Problem with Pepcid, Part 2: How to identify & manage nausea in your cat
By Laurie Goldstein, September 2015

In Part 1, we discussed how long term use of antacids may raise stomach pH, which can cause

– bacterial infection, bacterial overgrowth, small intestinal bacterial overgrowth (SIBO),
– bile acid deconjugation (a common and often diagnosed cause of fat malabsorption and chronic diarrhea, distinguished by yellow or green watery stool);
– nutrient deficiencies, notably B12, iron, calcium, zinc, folate, and vitamin D; and
– reduced gastric emptying times. Delayed gastric emptying can result in pain, loss of appetite, feeling full after eating only a little bit, and changes in blood sugar levels.

It is important to note that these are risks, not givens, and that the probability of problems is higher with proton pump inhibitors (like Prilosec (omeprazole)) than with the H2 blockers (like pepcid a/c (famotidine) and Zantac (ranitidine)). Antacids can safely be used short term to stop a cycle of nausea and inappetence; sometimes a few days is all that is needed. If it isn’t, then it is best to identify and address the underlying cause. Obviously, treating the cause is always better than treating the symptoms when possible, and apart from treating stomach ulcers and/or rare hyperacidity, all other uses of antacids simply suppress symptoms. Of course antacids can be used for longer periods, and the H2 blockers have a lower probability of the side-effects occurring compared to the proton pump inhibitors, but such use should only be done with vet awareness and supervision despite the availability of these drugs without prescription. That said, here in Part 2, we focus on how to identify and address the source of the nausea rather than just suppress the symptoms.

Identifying Nausea and GI Distress
It is quite common to think one’s cat is being finicky when the problem is actually nausea. Part of the problem is that there is no one symptom that is specific to nausea, and cats, of course, are well known for hiding any illness or injury if they can.

Any one (or combination) of these symptoms can indicate your cat is feeling nauseous:
Loss of appetite
Acting hungry but walking away from food
Just licking at or sniffing food
Head hanging over water dish but not drinking
Vomiting water
Vomiting frothy foam (bile) (it can be white, yellowish, or tinted red)
Lip licking or lip smacking (which can be a sign of nausea OR dehydration)
Drooling
Eating grass or plants
Pica, often licking or nibbling plastic, eating plastic plants
Sitting in a “meatloaf” position (see pictures, below)
Howling/Yowling (often indicates pain if such vocalizations are not normal in your cat)
Immediately regurgitating after eating

Of course, most things on this list can have a different cause at their source. This is one of the great difficulties when trying to diagnose and treat cats.  Many problems present the same symptoms, and each set of symptoms may indicate a variety of potential problems. No matter the cause, if kitty is displaying any of these symptoms in combination with behavior that indicates she isn’t feeling well, a vet trip is in order. Don’t let paranoia take over, but with cats, a touch of paranoia is better than putting off a vet trip until a problem reaches obviously serious status.

Behavior that indicates any of the above symptoms are related to illness:
Changes in litter box habits (eliminating out of the litter box)
Changes in bowel movements or urination frequency
Changes in social interaction (hiding or not interacting with you or other pets as they normally do; aggression on petting or brushing can indicate pain)
Changes in activity (lethargy – cats don’t usually slow down much as they age; more activity – this can be caused by hyperthyroidism)
Changes in sleeping habits
Changes in grooming habits (greasy or matted fur; dandruff; reduced grooming)
Changes in vocalization
Bad breath (this can be related to a dental problem or a GI problem).

Too many times, people, even vets, may think a problem is just “old age,” but that is rarely the case in cats. Remember that cats are usually not fond of change, so when they change in appearance or behavior, there is likely to be a specific cause. We often don’t observe our fur companions closely until they get sick, but it’s helpful to take note of body language now so you’ll know when something isn’t right. It is the same with blood tests. A test done while a cat is healthy supplies a baseline for later. It’s one thing to know what the lab norms are, but just as in people, “normal” varies at times from cat-to-cat. Know your cat’s normal so when kitty is “off” the change in blood values can be identified. A physical exam, blood work, perhaps an x-ray, and/or an abdominal ultrasound will be a part of the diagnostic process.

Note: Vomit that looks like coffee grounds means there is active bleeding in the stomach, often from ulcers. This is an emergency, and you should get kitty to your vet or an emergency vet as soon as possible. Red tinged vomit indicates ruptured capillaries in the esophagus and is usually from the irritation to the throat from vomiting. This is of concern if it happens frequently, but again, a vet check is always best.

Meatloafing: comparing comfortable positions with those indicating nausea

The every-day meatloafs
There are four basic “meatloaf” positions. The first two pictured here are normal, every-day positions; the final two are indications your cat feels sick and/or is in pain.

Happy, relaxed, not nauseous:

Not necessarily relaxed, this pose says “this is my spot.” But it doesn’t indicate nausea.

Looks uncomfortable, possibly in pain, head down

Clearly uncomfortable, sitting forward on haunches, in pain, sometimes with head down, eyes squinted.

Treating Nausea and Vomiting: Food
Apart from using medicine (prescription or over-the-counter) there are three basic components of treating GI problems in your cat: food, supplements, and water. We also address hairballs, a common cause of nausea and vomiting in cats.

Food
Issues that can cause GI problems:

1.    What is fed
2.    How it is fed
3.    When it is fed

What is Fed
Cats are obligate carnivores. Their natural diet consist of small prey animals. Some argue they naturally consume carbohydrates because of the stomach and intestinal contents of the prey. An examination of the diet of feral domestic cats (that have access to very little human food or garbage) found the stomach contents of prey provide very little in the way of carbs: just 2% of the diet on an energy basis. This author notes that the contents of the stomach and intestines are, for the most part, predigested. Thus feeding our cats a species-appropriate (low carb, grain-free, meat-and-organ based) diet can be the difference between a sick kitty and a healthy kitty. Some food companies and vets maintain that cats can metabolize carbs, which they can. But there is a big difference between “can” and “should.” Also, there remains a question of at what point carbs become a problem. For those that want to stick with commercial diets, a food that contains 40% carbohydrates (usually measured on a dry matter basis, a downloadable carb calculator in Excel is available, here) is simply not going to be a good long term choice. When making food choices, bear in mind that vets that embrace our kitties as the obligate carnivores they are, but are not anti-carbs in their diet, usually suggest no more than 20% of the diet be carbs. There is no research to indicate one way or another whether that level of non-meat based ingredients will take a toll on your kitty’s organs over time or not. One thing is clear: the physiology of a cat indicates they are not intended to derive much energy or nutrition from grain-based foods or intake of carbohydrates. Feed low carbs.

If cats were in charge of the pet food industry, cat food instructions would likely read, “remove mouse, rabbit or small bird from freezer: thaw and serve.” Anything else is 1) for our convenience, 2) due to our access to feeding resources, or 3) due to the cost of feeding. When our cats get sick, we need to learn how to best balance our time and resources with their needs. So please know that:

⦁   Grains can cause nausea and vomiting.
⦁  Non-grain carbohydrates such as peas can cause nausea and vomiting. This is tricky, because many Limited Ingredient Diets contain peas to raise the protein level and lower the cost. Anecdotally, we’re finding more and more IBD cats reacting to the peas in the food.
⦁  Otherwise high carb foods can cause nausea and vomiting. Many “grain-free” foods simply replace grains with non-grain starches. The problem? Carbohydrate ingestion does not trigger the same gastric secretion as meat-based proteins. A high carb diet can raise stomach pH, leading to improperly digested protein and/or delayed gastric emptying, contributing to nausea and/or vomiting.
⦁  A carb “red flag:” Meat is high in methionine, an amino acid used by many companies as a urine acidifier. If the synthetic version, “DL-methionine” is supplemented, especially if you find it towards the top of the supplement list in commercial food ingredients, alarm bells should go off; this is an indication the food does not contain protein primarily from meat or that the food is otherwise high in carbohydrates. Those carbs make the entire GI system, not just the stomach, too alkaline, and this can lead to various issues, among them urinary tract health problems and the formation of crystals. Natural methionine is found in meat, one of the reasons a meat-based diet naturally targets the proper pH in cats.
⦁  The many thickeners in most commercial canned foods can cause nausea, vomiting, and GI irritation. Thickeners and gelling agents include carrageenan, xanthan gum, guar gum, locust bean gum, cassia gum, agar agar, tapioca, potato starch, and wheat gluten. This list is not complete, but these are common additives for thickening and gelling. Any or all of them can cause stomach upset and nausea.
⦁  Food/ingredient sensitivities can cause nausea and vomiting.
⦁  Food allergies can cause nausea and vomiting. Grains are a common culprit. A frequently-fed protein can be the cause.
⦁   Kibble is often a culprit. Whether it is problem ingredients, the highly processed nature of kibble, or its impact on stomach pH and motility (due to being free-fed no matter the quality of ingredients – see Hairballs, below), simply removing kibble from the diet provides relief in many cats.

How Kitty is Fed

⦁  Raise the dishes. Cats normally eat sitting or standing so their throat is at the same height or lower than the stomach. If kitty does have problems with acid reflux, raising the food and water dishes to head-height (while sitting up or standing) can resolve this problem.  In Part 1 we discussed how acid reflux is not caused by excess acid; it is a problem with muscle tone in the lower esophageal sphincter, the valve that is meant to prevent stomach acid from rising into the throat. By keeping the head elevated and letting gravity work, the raised dishes keep the stomach acid in the tummy. Once there is food in the stomach, the acid is put to work.
⦁  Slow kitty down. When a cat eats too fast and regurgitates as a result, this is almost always when kitty is being fed kibble. Rather than put a rock or ball in the dish to slow down kitty, please just stop feeding kibble. If kitty manages to wolf down food so fast they regurgitate canned, homecooked, or raw food, then portion out smaller amounts and extend meal time to numerous smaller meals over 10 or 15 minutes vs one plop of food in a dish left out for 10 to 15 minutes. (And bless you for having adopted a formerly abused cat or kitty rescued from a hoarding situation, as this is behavior displayed most often by cats in those situations. Feral cats that almost starved usually slow down pretty quickly on their own once they realize food is provided regularly. Please don’t underrate the importance of emotions and psychology in cats. Please take the time to treat the whole kitty, and that’s more than just the body).

When Kitty is Fed

⦁  Feed smaller, more frequent meals. Two meals a day is not ideal for cats. Their systems are geared toward eating more frequent smaller meals (as in the wild they hunt small prey). Add a meal as late as possible before you go to bed. Reducing the length of time between the last meal of the day and the first meal of the next day often stops overnight bile pukes.
⦁  Feed a freeze dried meat treat to kitty when you get up, and/or prior to bed, and/or in the middle of the night, and/or prior to meals. The anticipation of food gets the gastric juices flowing. Giving kitty a protein-based meat treat that puts those gastric juices to work can stop the morning (or overnight) bile pukes, and can stop the regurgitation of the morning meal. In some cases, a middle of the night treat will resolve pre-breakfast vomiting better than any medicine. For those making a trip to the bathroom in the middle of the night, taking the time to give kitty a treat can improve your cat’s morning – and yours as well. If bile pukes happen during the day, or meal regurgitation is a frequent occurrence, feed kitty a few small bites of freeze-dried meat treats as needed, when you get home from work, or about 10 to 15 minutes before each meal to see if that resolves the problem. Pure Bites, Whole Life, and Grandma Lucy’s are popular brands of single-ingredient meat treats made in the USA.
⦁  Stop free-feeding and move to timed meals. (Better yet, stop the kibble). In cats, indigestible solids (such as hair) are the last items to leave the stomach. They are forced out of the stomach only by the strong peristaltic waves created by hunger pangs. If kitty is never hungry, motility is impaired and waste material does not move through kitty’s system properly. Obviously this can cause nausea, and a belly full of hair or improperly digested food can cause a loss of appetite as kitty feels full. (For transition tips and how to help kitty understand the concept of meal time, please see Transitioning to Timed Meals OR New Food)
⦁  For more on the timing of meals for kitty, please see How often should you feed your cat?

Hairballs
Hairballs are by far the most common cause of nausea, inappetence and vomiting in cats. And yet hairballs are NOT normal. I know it’s news to many. But a healthy cat does not normally have anything other than an occasional hairball, and tossing a hairball more than twice a month in long-haired cats and more than once every two months in short-haired cats can be indicative of GI disease. A study published in 2014 found that 99 of 100 cats examined for chronic vomiting – including tossing hairballs – had GI disease. Of those 99 cats, 50 had some form of cancer, and 49 had some form of inflammatory bowel disease. Many may still joke about hairballs, but hairballs are NOT a joke.

A primary symptom of hairballs is regurgitating undigested food hours after eating. Prior to this point, kitty feeling full and seeming “picky” about eating can be a subtle sign of hairballs:

1. Cats with hairballs often seem “picky” but otherwise fine: they don’t necessarily display any signs of nausea other than wanting to eat but not eating;

2. Kitty regurgitating the meal undigested hours after eating is often hungry immediately, and displays no other behavioral signs of illness.

To address hairballs in our cats, it is best to:

⦁  Stop free feeding and feed timed meals (addressed above)
⦁  Stop feeding kibble (feed canned, cooked, or raw food – food with moisture)
⦁  Feed species-appropriate food (low carbohydrate, no grain foods, addressed above)
⦁  Forget the petromalt or petroleum-based hairball products. It is best to address hairballs by treating the underlying problem: GI motility. If a species-appropriate, moist food fed in timed meals does not resolve the problem.

Identifying Food-related Problems
When there is nausea or vomiting, if kitty is diagnosed as having Inflammatory Bowel Disease and/or Pancreatitis, then food sensitivities/allergies need to be ruled out as a cause. Many traditional vets recommend “Novel proteins,” “Limited ingredient diets,” “Allergan-free diets” or “Hydrolyzed protein diets,” many of these being prescription diets. The problem? This approach is the equivalent of throwing spaghetti at the wall to see what sticks, and many of these foods have a poor ingredient list for long term use. It is much, much simpler to stop ALL commercial food and feed kitty a simple, meat-only bland diet short term. Think of it as plain chicken soup for a person with the flu.

The Bland Diet. If your cat is frequently nauseous or vomiting (or has diarrhea and parasites have been ruled out), consider stopping ALL food and treats, and feeding a bland diet (even better if with a novel protein) for a week or two (less in young kittens. Some vets approve this unbalanced diet for up to a month. Please discuss this with your vet). In cats, this is either a prepared meat-only baby food or a meat you poach at home. This bland diet is NOT nutritionally balanced and is for SHORT TERM USE ONLY. But just as drinking only chicken stock does not hurt us while we have the flu, eating just plain cooked meat will not harm your cat for a few days or few weeks. It is immensely helpful in quickly identifying if the food they’ve been eating is causing the problem.

In the U.S. the best baby food option is Beechnut or Goya as they are made with the water the meat and bone are cooked in (and then the bone is removed). This is the “broth” in the ingredient list. No, it is not seasoned with anything. Neither brand uses corn starch as a preservative (Gerber does). Consider using the turkey as your kitty has likely had less exposure to this protein vs chicken. The stage I, meat-only baby foods contain no spices or seasoning. If poaching a meat at home, it is important to include the water in which the meat was poached as part of the meals. The meat can be fed shredded in some of the broth, or the broth and meat can be blended together. Consider using boneless pork, as this is very likely a “novel” protein for your cat. Kitty won’t eat it? Try a different protein. If the nausea was severe, you may have to assist feed your cat for a day or two to give the bland diet a chance to settle the tummy. If problems continue or worsen, try a different meat before giving up. Cats are very strong creatures, but also idiosyncratic, as most kitty companions know very well.

Make and feed bone broth as a supplement to the bland diet. Bone broth is both nutritionally dense and yet extremely easy to digest. It is very healing and very soothing. In fact, you may need to feed bone broth for a day before kitty feels like eating the bland diet on her own. (Caution: Do not let your cat eat only bone broth for more than a day, and if your cat has liver disease, has been diagnosed with Inflammatory Bowel Disease or pancreatitis, do not let them go without food for more than 12 hours at most. Cats need close to their full complement of daily calories to prevent a liver disease caused by not eating, called hepatic lipidosis or “fatty liver.” The treatment for fatty liver is food. So best just to ensure kitty gets all they need in the first place). For bone broth instructions, see Dr. Becker’s video or transcript (if a chicken allergy is suspected, make the broth with bone-in turkey or pork or beef. There is no need to cook the larger bones to complete mush). Susan Thixton of Truth about Pet Food has written up a nice piece on the benefits of bone broth, though I do recommend following the instructions of the two-stage process that uses meaty bones as described by Dr. Becker, and keeping out some of the meat broth from Stage I before continuing to Stage 2. Some cats do not like the stage 2 broth. That’s fine, the meat broth is also very nourishing and soothing.

Has kitty improved on the bland diet? Then you know food is the problem. At this point, you MUST think of food almost as a medicine: food is the key to your cat’s health and happiness. Food can help heal or hinder the well-being of your cat. You can start trying different commercial canned foods, or you can just go straight to a commercial raw product for a minimally processed, fresh food option. Of course, making homemade fresh food where you control the ingredients is an option. It is more than just offering meat, but it isn’t rocket science.

Do not be surprised: Kitty may not like the food you make. Yes, this is disappointing, of course! But if all I’d ever eaten was dry cereal or canned stew, I probably wouldn’t like a salad or fresh fruit. It looks weird, has a strange texture, the temperature is likely different. So if kitty doesn’t take to the food right away, you need to give kitty time to transition. They will come to like, even love the food. They just need time. Transition help is available here.

As to making your own food, there are many ways to do this: cooked or raw; chunky meat and organs with bone-in meals (called “prey model raw”); an easy properly balanced vitamin premix added to meat or meat and liver. You may wind up wanting to move to prey model raw if feeding ground, or you may want to buy a grinder to manage making bone-in homemade ground. You may want to move to raw from cooked. There are no right answers here, these are all decisions of personal choice based on your lifestyle and your cat’s tastes and needs. None are particularly difficult; some approaches require investment in kitchen equipment. But when food is the problem, making one’s own and transitioning kitty with a slow introduction is often much easier in the long run than getting back on the food merry-go-round.

Do be aware, if you begin making homemade, it is important to include at least three proteins in rotation so that your cat does not develop a protein allergy/sensitivity and so that kitty does not reject the food due to boredom. Yes, even in your cats with IBD, these different proteins can be alternated at every meal, or every day, or every week. They do not need to be fed months at a time. Many kitties, once on raw, prefer the variety when offered more frequently.

Finally, it bears repeating: feeding a homemade diet is not just offering up meat. Cats need the minerals from bone and the dense nutrition in organs, and these need to be fed in proper proportion. Far too often we see people feeding just meat thinking they are doing something great for kitty, but this is a recipe for disaster. Here we’ve pulled together a list of approaches and recipes that are nutritionally balanced. All are simple and straightforward. They range from needing a grinder that can handle bones, to simply needing a food scale.

Please see the recipe for Easy Home Cooked Cat Food using a supplement premix that makes just meat and liver (in proper proportions) balanced and complete. The posted recipe is for making cooked food for kitty, as not everyone wants to feed raw. But please know the supplement used in this recipe was designed for balancing raw food, it just also balances cooked food. So the same recipe can be used to make raw or cooked food. If making raw, simply do not cook the meat and liver! Does not require a grinder, but does require a food processor and potentially a slow-cooker (though meat and liver can be cooked on the stove or in an oven, just use ALL of the water or pan drippings).

In Summary
As with people, in cats food is very frequently the root cause of nausea and vomiting (and for those with it, their diarrhea). Medicine is not the best answer when food is the problem. Medication is an important tool, and has its proper time and use. But altering what, how, and/or when we feed is often all that is needed to make kitty feel better. Feeding fresh food where we control the ingredients is sometimes needed, but in this author’s opinion, always preferable. Our cats are obligate carnivores. Their physiology is “designed” to have a low stomach pH and to eat primarily meat (bone and organ). Our cats are descended from desert animals and while some may drink water, cats do best when fed a moist diet, better yet, a fresh food diet. In many instances, identifying a problem ingredient can be difficult, and it is easiest to help our kitties feel better by simply getting off the commercial food merry-go-round. Transitioning is not always easy, but there are many tricks, tips, guides and resources to help. Persistence ALWAYS pays off. The road to good health is not a race, it is a journey.

Supplements, hydration, and medicines to manage ongoing problems with nausea that are not food related will be covered in Part 3.

And a shout out with thanks to Forrest D. Poston for the thoughtful input.

References
Funaba et al 2003. Effects of a high-protein diet versus dietary supplementation with ammonium chloride on struvite crystal formation in urine of clinically normal cats, Am J Vet Res, Aug; 64(8):1059-64 (2003).  http://www.ncbi.nlm.nih.gov/pubmed/12926602

Funaba et al 2004. Evaluation of dietary carbohydrate on formation of struvite crystals in urine and macromineral balance in clinically normal cats, Am J Vet Res
Feb::65(2):138-42 (2004). http://www.ncbi.nlm.nih.gov/pubmed/14974568

Norsworthy et al 2013. Diagnosis of chronic small bowel disease in cats: 100 cases (2008-2012), J Am Vet Med Assoc, Nov 15;243(10):1455-61 (2013).
http://www.ncbi.nlm.nih.gov/pubmed/24171376

Plain English summary, by Gary Norsworthy, DVM for Veterinary Practice News, January 2014: Chronic Vomiting in Cats isn’t Normal After All.
http://www.veterinarypracticenews.com/Chronic-Vomiting-in-Cats-isnt-Normal-After-All/

Plantinga et al. 2011. Estimation of the dietary nutrient profile of free-roaming feral cats: possible implications for nutrition of domestic cats, British Journal of Nutrition / Volume 106 / Supplement S1 / October 2011, pp S35-S48.
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8404219

The Problem with Pepcid, Part 3: Healthy Supplements
and Alternatives for Treating Nausea
Laurie Goldstein, Oct 2015

This is the final part of a three part series. In Part 1, we discussed how long term use of antacids may raise stomach pH, which in turn can cause a number of health problems. In Part 2, we talked about how to identify nausea in your cat (including subtle symptoms), hairballs, and how food is a primary source of tummy (and other gastrointestinal) troubles in our cats.

As the primary cause of nausea and vomiting in our cats is food related, often managing nausea and/or vomiting in your cat is as simple as finding a non-kibble, meat-based, grain-free, low carbohydrate food that agrees with your kitty. Sometimes this doesn’t seem so simple as your vet or other cat parents offer suggestion after suggestion and your “picky” kitty turns up her nose at food after food. But the short-term use of a bland diet makes food-related identification simple and straightforward. This frequently resolves the problem if there isn’t an underlying disease. A bland diet doesn’t identify the problem ingredient(s), but if the food your cat has been eating is the source of the problem, a bland diet will identify that. At that point, controlling the ingredients with balanced homemade fresh food is easy, whether cooked or raw. Commercial fresh food (raw) products are becoming more widely available, and often a species-appropriate, less processed food resolves the problem. If it is a protein sensitivity, a single-protein fresh food diet in rotation will identify the allergy.

If the bland diet resolves the problem, great! We know how to proceed. If not, until – and if – we can identify the source of the nausea to treat it, or if kitty has a condition that requires ongoing nausea management, there are healthy alternatives to Pepcid a/c (famotidine) or Zantac (ranitidine) that may resolve the nausea without the potential long term use side-effects. These include:

For Immediate Relief
Slippery elm bark powder
Distilled or organic aloe vera juice (made from the inner leaf gel only)
Acupuncture
Proper hydration
B12

Longer Term Management
Probiotics
Digestive Enzymes

Any or all of these can be used together. In fact, probiotics, slippery elm bark powder, and the aloe vera juice (that contains no latex) work together synergistically.

Prescription Alternatives: Anti-emetic (central nausea) medications
Cerenia (maropitant)
Zofran (ondansetron)

We note that many cats are prescribed reglan (metoclopramide). This medicine increases muscle contractions in the upper digestive tract and triggers gastric emptying. This drug can be an important short term tool, but it causes serotonin syndrome and/or extreme anxiety and restlessness in many cats. Longer term use can cause an irreversible movement disorder.

Management of Nausea in Chronic Kidney Disease
For cats in chemotherapy or with chronic kidney disease (CKD), medical management may be necessary. Nausea in CKD is often ascribed to acid overproduction, but a study published in 2014 found this not to be the case. Cats, unlike dogs and humans, appear to suffer from central nausea, not gastritis related to acid overproduction. The study found “gastrointestinal signs noted in CKD cats may be more the result of uremic toxins and centrally acting emtogens than due to pathology within the stomach. The more common administration of antacids and gastroprotectants in cats may not be justified. … Management of gastrointestinal signs by use of antiemetic and antinausea drugs may be more worthwhile in cats with CKD.”

The two most commonly prescribed antiemetic drugs that treat central nausea in cats are Cerenia (maropitant) and Zofran (ondansetron). If one doesn’t work, try the other. Also, any of the alternative nausea treatments discussed here can safely be used in kitties with CKD. Fluids and B12 are likely already a part of their treatment plan.

Alternative Nausea Treatments
Slippery Elm Bark Powder
Slippery elm bark powder (SEB) is safe and non-toxic for cats. It may interfere with metabolism of medicine, so please give any meds at least 2 hours before or after giving it to your kitty.

Often SEB is all that’s needed to settle an upset stomach. As Dr. Hofve says, “It can be thought of as a sort of natural “Pepto-Bismol.” (Pepto-Bismol itself should not be used because it contains salicylate, a.k.a. aspirin). Its mucilage content coats, soothes, and lubricates the mucus membranes lining the digestive tract. Slippery Elm is an excellent treatment for ulcers, gastritis, colitis, and other inflammatory bowel problems. It is high in fiber, and so helps normalize intestinal action; it can be used to relieve both diarrhea and constipation. It may also help alleviate nausea and vomiting in pets suffering from non-GI illnesses, such as kidney disease.”

It is best if purchased as loose powder rather than in capsule form, as flow agents are required in the product when encapsulated. For nausea, it works best as a kind of “gruel” (gel) or “syrup” and given one-half hour to 45 minutes prior to a meal. Given kitty is nauseous and inappetent, you will most likely have to syringe it if made into a syrup, or spoon or finger feed it if used as a gel or “gruel.”

For the quick thick gel, mix one-quarter teaspoon of the powder with one-half teaspoon of water. Let it thicken. You may need to add water to get it into the syringe, that’s OK. Give 3 – 5ML (CC).

For the “syrup,” mix 1 teaspoon of SEB powder with one cup water. On the stove: bring to a boil, then let simmer for three to four minutes, whisking basically constantly. It will thicken as it cools. In the microwave: heat on high 30 seconds, stir. Repeat. Then cook it at 50% power for four minutes, stopping it every 20 to 30 seconds to stir so it doesn’t boil over. This can be refrigerated for up to 5 days, just take it out to use as needed.

For more information on slippery elm bark powder, please see:
Tips & Tricks

The Numerous Healing Properties of Slippery Elm
http://www.promedics.ca/site/downloads/Slippery%20Elm.pdf

Aloe Vera Juice (Distilled or from inner leaf only, no juice containing latex)
Aloe vera is well known for nutrient compounds that help heal and soothe the skin when used externally; it has similar benefits on the lining of the digestive tract when taken internally. Aloe decreases irritation and enhances healing and repair of ulcers in the stomach and intestines; it helps reduce intestinal inflammation. It can neutralize excess stomach acid without the pH rise associated with antacids over time, and it acts as a prebiotic, helping to promote the growth of healthy bacteria that aid digestion.

Up to twice a day, distilled aloe vera juice can be used in place of water to make the slippery elm bark gel or “gruel.” If not using SEB powder, one-half teaspoon of aloe vera juice can be given to kitty to drink or administered plain, via syringe, prior to a meal twice a day. It can also be mixed into food: this promotes healing longer term, but it doesn’t provide nausea relief if kitty isn’t eating.

Longer term, combining SEB powder, aloe vera juice, and a probiotic is an anti-inflammatory therapy that aids gastrointestinal health. To use this, mix one part SEB powder to 2 parts aloe juice (1/4 teaspoon SEB powder and 1/2 teaspoon aloe vera juice). Let it gel. Add and mix in the probiotic of choice. This can be given twice a day, and this can be added to food (if kitty is eating).

In the U.S. we suggest George’s or Lily of the Desert organic preservative-free unflavored juice. The organic is a bit bitter and kitty may not like it; the George’s has no taste but is not organic.

For more on Aloe Vera Juice, please see
Aloe vera and GI Tract Health
https://www.lorandlabs.com/pdf/Aloe%20Insight%20-%20Aloe%20vera%20and%20GI%20Tract%20Health.pdf

Health Risks & Benefits of Taking Aloe Vera Juice Internally
http://healthyeating.sfgate.com/health-risks-benefits-taking-aloe-vera-juice-internally-5017.html

Aloe Vera Gel Research Review
http://naturalmedicinejournal.com/journal/2012-09/aloe-vera-gel-research-review

Acupuncture for Nausea
To date, more than three dozen randomized controlled studies have been published showing that acupuncture point stimulation can treat or prevent nausea and vomiting. If you are in the U.S., you can search http://www.ahvma.org to see if there is a vet trained in acupuncture near you. I also recommend using an internet search to look for “holistic vets,” “Integrative vet,” “acupuncture vet,” etc. in combination with the name of your town, county, or nearby large city (if there is one).  For the scientific-minded, this study (originally published in Hebrew) discusses how acupuncture works in managing nausea. How often your cat would benefit from the treatments will be discussed with the vet. But acupuncture in cats has proven to be very effective at helping treat nausea and usually results in an increased appetite.

Proper Hydration
Chronic vomiting or diarrhea, or a bout of vomiting or diarrhea can cause dehydration. Even subtle, mild dehydration can make your cat feel worse and exacerbate nausea. Sometimes fluid administration helps tremendously. This is obviously true for CKD cats who run the risk of dehydration due to improperly functioning kidneys and frequent urination. This may also help diabetic cats and cats with hyperthyroidism while you work to find the correct doses of medication to manage the diseases. Talk to your vet about administering sub-q fluids at home. If it is deemed safe and appropriate for your cat’s circumstances, having fluids on hand can make a real difference in how your kitty feels.

If you do not have sub-q fluids on hand, you can offer “tuna water” (drained from a tin of tuna); or slowly syringe plain water or coconut water (make sure it is unflavored with no preservatives). Coconut water is very similar in make-up to oral rehydration solutions, it contains properly balanced electrolytes naturally – but it does contain sugars. The use of children’s unflavored pedialyte is controversial due to the dextrose (sugar). Plenty of vets suggest it; others feel strongly the sugar is inappropriate for our obligate carnivores. But if your cat has been vomiting and is dehydrated and you don’t have sub-q fluids on hand, a homemade oral rehydration solution can get your kitty through the night and to the vet the next morning.

Oral rehydration solution: I make it by boiling, then cooling, one cup of water, and adding a small pinch of baking soda, a small pinch of salt, and a teaspoon of raw, organic honey. You can use a teaspoon of table sugar instead of the raw honey (do NOT use honey if it is not raw, the regular sugar is better). If the use of sugar, diluted, in such small amounts for a short period of time makes you uncomfortable, just syringe plain water and call the vet ASAP. But if you have a diabetic cat and your kitty is vomiting to the point of dehydration, if you can’t get to an emergency vet, that little bit of sugar may be a life-saver.

B12 Shots
For GI diseases that involve inflammation and malabsorption (such as inflammatory bowel disease, exocrine pancreatic insufficiency, pancreatitis, or intestinal lymphoma) or increased thirst and thus urination (such as hyperthyroidism, diabetes, or chronic kidney disease), B12 shots should be considered essential, in my opinion. Like fluids, vitamin B12 supplementation greatly enhances kitty’s well-being. B12 is water soluble, so even if B12 levels are not found to be low in blood work, your cat may benefit. It will not harm your cat to try, so ask your vet! https://ibdkitties.net/the-importance-of-b12/

Probiotics
Recent research has made it clear that we depend on our healthy bacteria for our health. In fact, our bacterial balance is so important to our immune system and digestive function, it can almost be thought of as another organ. A report published in September of this year put it this way “It is comparable to the immune system in as much as it is made up of a collection of cells, it contains a 100 times more genes than the host, is host-specific, contains heritable components, can be modified by diet, surgery or antibiotics, and in its absence nearly all aspects of host physiology are affected.”

Probiotics help us and our cats metabolize nutrients from our food, prevent the overgrowth of unhealthy bacteria, support almost every aspect of our immune system, regulate our moods, our weight, resolve and prevent allergies, regulate inflammation, and appear to help protect against several gastrointestinal-related cancers.

In the wild, a cat essentially gets a dose of probiotics with every meal. By eating the guts of its prey, kitty has a constant supply of bacteria to “feed” its gastrointestinal tract, its “microbiome.” The diet we feed our cats, even those feeding fresh food, is devoid of probiotics unless we supplement them.

Unfortunately, only limited data is available about the bacterial profile of cats. A May 2015 study of the fecal microbiome in cats with diarrhea was compared to healthy cats and significant differences were found: gut dysbiosis (the balance of GI bacteria) plays a very real role in the proper function of our cats’ GI system. Many recommend using “species-specific” strains of bacteria, as our cats do have bacteria that are unique to them. Ideally, we would provide bacteria derived from cats for best results. But so little is known about cat-specific species, one of the lead researchers in the field feels that probiotic selection for use in pets should be based on researched strains, not whether or not the probiotics are pet-specific, and indicates “studies have shown that human or dairy developed probiotic strains are capable of conferring health benefit across species. At this point there is no proven benefit of using a canine or feline specific strain.” Probiotics will not resolve nausea or vomiting in your kitty on a “per dose” basis. They are a supplement that usually works over time, not right away. Brands and doses for cats are discussed here: (insert link for ibdkitties)

Digestive Enzymes
According to Dr. Jean Hofve, “Digestive enzymes help our pets to fully break down foods so nutrients can be efficiently absorbed and used by the body. When food is not properly digested, some particles may trigger inflammation, allergies, and other chronic health problems. Processed foods have had their native enzymes destroyed, so it is important to add them to your pet’s food. Plant- or fungal-based enzymes work in the widest range of pH and temperature. Make sure that the product you select contains at least protease, amylase, lipase, and cellulase.” Fat malabsorption is a common problem for cats with brewing GI issues. This is often a cause of gas, discomfort, and stinky stool (usually in the form of diarrhea). Kitty should be taken to the vet for blood work to rule out Exocrine Pancreatic Insufficiency (EPI), and https://ibdkitties.net/pancreatitis/epi/. But in the absence of EPI, digestive enzymes can greatly benefit kitty’s GI health, comfort, and nutrient absorption.

For more information, please see
Digestive Enzymes   http://ivcjournal.com/digestive-enzymes/

Summary
Digestive problems are so widespread in cats, according to VPI Insurance, they have ranked as one of the top two reasons for a vet visit seven out of the last nine years. Nausea and inappetence – “pickiness” in our cats – is not something to be taken lightly. One retrospective study of 100 cats with a history of chronic vomiting, weight loss, chronic diarrhea or a combination of those, found that 99 of those cats had either cancer or inflammatory bowel disease. Plenty of jokes abound about what we perceive as our haughty feline companions, or we write off our kitty’s problem as “just” hairballs or “he’s just a puker.” Cats should not be puking, they should not be sensitive to foods, and they should not be tossing hairballs with any frequency.

In some cases, the reputation of our “picky” eaters is merited: but for many, that pickiness we observe is actually a communication and the first indication that something isn’t right. Picky kitties are often actually at least slightly nauseous kitties. Clearly the first step is a visit to the vet. But if no underlying disease or cause is found, please remember as discussed in Part 2, the food we feed is often the culprit. If food changes as outlined don’t help, or if there is underlying disease that requires management of nausea, we hope these nausea management approaches help minimize the need for the use of antacids. Antacids are an important tool in the medicine chest, but it is best for kitty’s long term health to use them sparingly if possible.

References
Eamlamnam et al 2006. Effects of Aloe vera and sucralfate on gastric microcirculatory changes, cytokine levels and gastric ulcer healing in rats, World J Gastroenterol Apr 7; 2(13):2034-9 (2006).
http://www.ncbi.nlm.nih.gov/pubmed/16610053

Hofve, Jean DVM. Digestive Enzymes, IVC Journal; Spring 2012.
http://ivcjournal.com/digestive-enzymes/

Humphries C. 2015. The Deep Symbiosis between Bacteria and Their Human Hosts is Forcing Scientists to As Are We Organisms or Living Ecosystems? Seedmagazine.com October 11, 2015.
http://seedmagazine.com/content/article/the_body_politic/

Kumar et al 2010. Cancer-preventing attributes of probiotics: an update, Int J Food Sci Nutr Aug; 61(5):473-96 2010.
http://www.ncbi.nlm.nih.gov/pubmed/20187714

Marchesi et al 2015. The gut microbiota and host health: a new clinical frontier, Gut Sep:1-10 2015.
http://gut.bmj.com/content/early/2015/09/02/gutjnl-2015-309990.full

Marshall-Jones ZV 2006. Effects of Lactobacillus acidophilus DSM13241 as a probiotic in healthy adult cats, Am J Vet Res Jun;67(6):1005-12 (2006).
http://www.ncbi.nlm.nih.gov/pubmed/16740094

McLeland SM & Lunn KF et al 2013. Relationship among serum creatinine, serum gastrin, calcium-phosphorus product, and uremic gastropathy in cats with chronic kidney disease. J Vet Intern Med. May-Jun; 28(3)827-837 (2014).
http://www.ncbi.nlm.nih.gov/pubmed/24628683 and please see also
http://www.winnfelinefoundation.org/education/cat-health-news-blog/details/cat-health-news-from-the-winn-feline-foundation/2015/01/16/uremic-gastric-changes-in-cats-with-chronic-kidney-disease

Reynolds BC, Lefebvre HP. Feline CKD: Pathophysiology and risk factors—what do we know? J Feline Med Surg Sep; 15 Suppl 1:3-14 (2013).
http://www.winnfelinefoundation.org/education/cat-health-news-blog/details/cat-health-news-from-the-winn-feline-foundation/2015/01/16/uremic-gastric-changes-in-cats-with-chronic-kidney-disease

Samuels N. Acupuncture for nausea: how does it work? Harefuah Apr; 142(4):297-300, 316 (2003).
http://www.ncbi.nlm.nih.gov/pubmed/12754882

Sierra-Garcia GD et al. 2014. Acemannan, an extracted polysaccharide from Aloe vera: A literature review, Nat Prod Commun Aug; 9(8):1217-21 (2014).
http://www.ncbi.nlm.nih.gov/pubmed/25233608

Suchodolski JS. 2011. Companion Animals Symposium: Microbes and gastrointestinal health of dogs and cats, J Anim Sci 89:1520-1530 (2011).
https://www.animalsciencepublications.org/publications/jas/pdfs/89/5/1520?search-result=1

Suchodolski JS. 2015. Probiotics in GI Health, Western Veterinary Conference Proceedings S22C, 2013.
https://www.facebook.com/groups/RawFedIBD/1440619959508838/

Suchodolski et al 2015. The Fecal Microbiome in Cats with Diarrhea, PLoS ONE 10(5): e0127378 May 2015.
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0127378

Wynn, SG 2009. Probiotics in veterinary practice, JAVMA 234(5):606-613 (2009).
http://www.winnfelinefoundation.org/education/cat-health-news-blog/details/cat-health-news-from-the-winn-feline-foundation/2009/04/02/probiotics-for-cats

Make your Pet a Healthy Broth
By Susan Thixton
http://truthaboutpetfood.com/

Grandma had it right; don’t toss those chicken bones or beef bones. Cook them into a tasty, healthy broth for your pet! Ok…Grandma used the bone broth as soup stock for people food, but I’m making bone broth for my pets. This is one easy way to provide your pet with a healthy, tasty snack. Little did I know my Grandmothers cooking was so healthy. Recent research led me to some fantastic information regarding the health benefits of cooking broth. Of course, my first thoughts were how wonderful this broth could be for pets.

While some professional chefs consider a broth to be made from simmering meat and a stock to be made from simmering bones, I’m considering our preparation (cooking bones) a broth. When you toss some bones into a pan of water, preparing to make broth, what you get is far more than what you see. Your broth will eventually contain ingredients that are in the bone. The following are explanations of all the goodies provided to your pet from home cooked broth; all quotes from a fantastic detailed explanation of the benefits of broth titled “Traditional bone broth in modern health and disease” by Allison Siebecker. While detailed and at points highly scientific, I think you’ll see the health potential of cooking bone broth for your pet.

“Basically then, broth will contain the ingredients that are in bone. Covering and adhering to the ends of bones to form a joint, is cartilage. Therefore broth will also contain the ingredients that are in cartilage. Bone and cartilage are both classified as connective tissue. Connective tissue is one of the four basic tissue types that exist in animals. It functions to bind or hold together and to support and strengthen the body. Since the cells are few, it is the valuable nutrients from the matrixes of bone and cartilage, which create the substance called broth.”

“Cartilage has enjoyed fame as a supplement for osteoarthritis in the form of shark cartilage. It has been studied for joint disease, and gastrointestinal disease. Prudden found that cartilage dramatically improved degenerative joint disease, including rheumatoid arthritis. He also found that it improved inflammatory bowel disease.”

“Cartilage has a poor blood supply. It actually produces chemicals known as antiangiogenesis factors (AAFs) that inhibit the growth of blood vessels into it. This seemingly unfortunate quality can actually be used to advantage in the fight against cancer. Cancer cells grow very rapidly. They achieve rapid proliferation by stimulating the growth of new blood vessels to support themselves. AAFs are now being used as a treatment to inhibit the growth of blood vessels into cancer cells. (10) As a medicine, AAFs are given in the form of cartilage.”

“Cartilage (broth) can be considered for use in the following conditions: arthritis, inflammatory bowel disease (Crohn’s disease and ulcerative colitis), cancer, decreased immune system states, and malnutrition.”

“One fourth of all the protein in the body is collagen. (15) It is the framework for the extra cellular matrix of bone, cartilage and skin. Another word for collagen is gelatin. Collagen is a scientific term for a particular protein in the body, while gelatin is a food term referring to extracted collagen.”

Another recent study found that “gelatin as feed supplement protected against ethanol-induced mucosal damages in rats.” This directly supports the traditional thought that broth is healing and coating to the gastrointestinal lining, and gives a scientific explanation for broth’s ability to calm and soothe. Gelatin has also been found to improve body weight as well as bone mineral density in states of protein under nutrition.”

“Also if gelatin is extracted from bone, then marrow, where blood cells are produced is also extracted. Chinese studies have shown gelatin to increase red blood cell and hemoglobin count, increase serum calcium level, increase the absorption and utilization of calcium, and prevent and treat myotonia atrophica (muscle wasting).”

“To summarize, gelatin (broth) can be considered for use in the following conditions: food allergies, meat maldigestion, hypochlorhydria, hyperacidity (gastroesophageal reflux, gastritis, ulcer) inflammatory bowel disease (ulcerative colitis), leaky gut syndrome, malnutrition, weight loss, muscle wasting, cancer, calcium deficiency and anemia.”

“Minerals have three major functions in the body. First, they provide a structural base for connective tissue like bone. Second, they create electrical potentials allowing for conduction of nerve signals and movement across cell membranes. Third, they act as catalysts for enzymes in physiologic processes, and as Paul Bergner says in The Healing Power of Minerals, “transform the food and air we breathe into energy, vibrant health, and consciousness.”

“Bone contains calcium and phosphorus, and to a lesser degree, magnesium, sodium, potassium, sulfate and fluoride. Bone is an excellent source of minerals.”

“Deficiencies of minerals can be acquired, similar to vitamin deficiencies. Generally there are two ways this can happen, lack of intake in the diet, or lack of absorption in the intestines. Broth can be an excellent remedy for both of these causes of mineral deficiency because it provides easily absorbed extracted minerals, plus promotes healing of the intestinal tract.”

Amazing huh! Simply put, cooking a bone broth removes “the active chemical ingredients into the water by means of heat, time, and acid, making the nutrients immediately available to absorb.”

Ready to cook?  Here’s your recipe…
Ingredients: Bones from poultry, fish, beef, lamb. Raw bones with or without skin and/or meat. (As example, I purchased a 3 pound package of chicken necks and chicken backs. $0.50 per pound. I did not remove the skin or fat, just dumped the contents into the pot. Later, after cooking, I removed the larger pieces with tongs, smaller pieces were removed via straining. Fat was skimmed off the top once the broth cooled.)

Add your choice of bones into a large pot or crock pot. Cover (just cover) the bones with cold water; or 2 cups of water per 1 pound of bones. Add 2 tablespoons of cider vinegar per 1 pound of bones. Let stand for one hour. Bring to a low boil, reduce heat and let simmer for 6 to 48 hours for chicken bones (bones will become soft when touched by a fork); 12 to 72 hours for beef bones.  Strain broth through a colander or sieve lined with cheesecloth (or paper towel). Discard bones (do NOT feed these bones to your pet). You can also cook bone broth in a crock-pot, low heat.

Broth can be stored in the refrigerator for up to 5 days or frozen for several months. Feed your pet the broth at non-meal times at least 30 minutes prior to a meal or 1 hour after (prior to a meal is better, aids in digestion of the meal). With IBD kitties it’s probably best to serve as a separate meal, but the extra moisture in a cat’s diet is a huge plus anyway you serve it. So it can be added to commercial canned food, home cooked or a raw diet if need be or desired.

My first bone broth test was with chicken bones (chicken necks and chicken backs). I am thrilled to report there was an eating frenzy with all of my gang. Three cats (one is extremely picky) did not raise their heads until the bowl was dry. Two dogs didn’t raise their heads until the bowl was dry. And I felt fantastic for cooking them up such a healthy treat. Broth has become a daily treat in my household, the gang is thrilled!

Also here is a video tutorial and explanation on why bone broth is good for pets:
Bone Broth: The “Soul Food” Perfect for Sick Pets Who Won’t or Can’t Eat
http://healthypets.mercola.com/sites/healthypets/archive/2013/12/02/pet-bone-broth.aspx

By Lisa Provost

B12 is water soluble and has the largest and most complex chemical structure of all vitamins. The list of benefits and symptoms of deficiencies are both long. B12 helps to support adrenal function, maintain a healthy nervous system, aid in the production of DNA and RNA, and the production of neurotransmitters. It affects the development and maintenance of red blood cells, nerve cells and normal myelination (the fatty sheaths that cover and protect nerve endings). It’s needed to prevent anemia, required for the proper digestion and absorption of food, and the metabolism of carbohydrates and fats.

A B12 deficiency can cause poor cell formation in the digestive tract and lead to nausea, vomiting, loss of appetite, poor absorption of food (malabsorption syndrome), constipation, gas, weight loss, fatigue, lethargy, abdominal pain, and/or diarrhea. Absorption of B12 requires normal function of the stomach, pancreas and small intestine. These are the very symptoms that cats with IBD and other gastric disorders exhibit. A B12 deficiency also inhibits and decreases the body’s ability to produce blood, increases blood cell destruction, and is very harmful to the nervous system which can cause neurological disorders and severe and sometimes irreversible nerve damage. Because a healthy liver is able to store many years worth of B12, signs of deficiency may not be obvious for a long time.

Normal function of the digestive system required for food-bound vitamin B12 absorption is commonly impaired in individuals over 60 years of age, placing them at risk for vitamin B12 deficiency. http://lpi.oregonstate.edu/infocenter/vitamins/vitaminB12/. This may be true of pets as well since they are living longer than ever before. No research has ever been done on this.

To be absorbed in the body, B12 needs to combine with a substance called intrinsic factor. IF is produced by your stomach lining where B12 from foods is released from its protein complex by hydrochloric acid and enzymes. The secreted IF will bind to B12 and this combination will travel to the end of the small intestine which then crosses the intestinal wall into the bloodstream. B12 is stored in the liver after being absorbed and anything not absorbed is excreted through the urine.

However, Intrinsic factor concentrates prepared from the stomach of one animal species do not in all cases increase B12 absorption in other animal species or in humans. There are structural differences in the vitamin B12 intrinsic factors among species. Similarly, there are species differences for vitamin B12 transport proteins (Polak et al., 1979).

The cobalt-containing B12 molecule is the largest molecule to be transferred across the intestinal mucosa and transfer occurs only in the ileum. B12 is generally absent from plant and vegetable food sources, unless the food is contaminated by microbes. Ingested B12 is bound to R-proteins and must be liberated by calcium, proteases, and bicarbonate in the duodenum before it can be absorbed. Free B12 then attaches to intrinsic factor (IF) to be transported across ileal cells as a dimer. It is then transported to the liver in the bloodstream bound to transcobalamin-2 (TC-2). The liver is a rich repository for B12 and releases it, as needed into the systemic blood stream. Deficiency of B12 or gastric, intestinal, or pancreatic disorders that affect the absorption of B12 will lead to B12 deficiency. Deficiency of B12 causes pernicious (megaloblastic) anemia by affecting DNA production.

Some risk factors for B12 deficiency are a weakened immune system and impaired white blood cells, gluten allergies and/or sensitivities, helicobacter pylori infection (a bacteria that can be common in IBD) Antacid, H2-blockers (the over use of antacids can cause low B12 and low platelets), anticoagulants and potassium supplements can impair the absorption of B12, broad spectrum use of antibiotics or anti-convulsants and parasites (specifically tapeworm). Large parasites like the beef tapeworm compete for nutrients by robbing the body of micronutrients and vitamins.

Regarding B12 injections for cats: there has been a lot of debate about cyanocobalamin vs methylcobalamin. This is understandable, it is a complicated subject. For humans, there is a lot of marketing promoting methylcobalamin as a superior supplement to cyano, given methyl is a bioactive form, and cyano is not. Yes, cyano is converted by the body into bioactive forms, and this is discussed in more detail, below. Methyl is used primarily in your liver, brain and nervous system and is needed for proper nervous system health. In people with liver disease, although high blood levels of vitamin B12 are common, it is not unusual to actually have a correspondingly low liver tissue concentration of vitamin B12 and its enzymes. With liver conditions, methyl B12 should be used because it helps the liver function much more efficiently. Methyl should be considered in the treatment of all neurological diseases including diabetic neuropathy. Cats with this condition are now being given a dose of at least 3,000 mcgs per day of Methyl B12 with amazing results!

In terms of using methyl instead of cyano for GI diseases, there’s no proof that methyl works better and in fact, methyl breaks down faster and contains a higher amount of preservatives than cyano does. You’re looking for something to have staying power, a longer shelf life in the body. Methyl B12 in the form of injections has no less benzyl alcohol and in fact may contain more than cyanoB12 injections. No version of these injections are without side effects, and caution should always be used. Do your research and make sure your vet knows what you’re giving your cat.

“Cobalamin” is what is termed a cofactor – a cofactor is “a non-protein compound needed for the protein’s biological activity.” There are two cofactor forms of cobalamin: hydroxocobalamin and cyanocobalamin. If a cofactor is organic, it is a coenzyme – the biologically active form. Methylcobalamin and adenosylcobalamin are coenzymes. The cobalamin cofactors go through a chemical process in the body to become coenzymes – but this is what is critical in GI disease – ***each coenzyme has different activity in the body.*** Methylcobalamin is ONE coenzyme, but the non-organic cofactors are metabolized into more than just one coenzyme. Methycobalamin is used specifically in the neural network, and this is why ALL of the “cobalamin” supplementation studies in cats use cyanocobalamin – because it is metabolized into more than just methylcobalamin.

The science on B12 insanely complicated, and they still don’t know much about the process in the body of cats. But what we do have are studies of “B12 supplementation” in cats that typically shows response and results, and the form used was cyanocobalamin. So while I don’t have scientific research that says methylcobalamin is not appropriate for treating B12 deficiency, you can easily find that all neurological-related supplementation is done with methyl, and all GI-related supplementation and research is done with cyano or hydroxo forms.

But importantly, cyano converts into methyl ***AND*** adenosyl coenzymes – and adenosyl is the one that is *required* for energy production by fats and proteins, and it is the adenosylcobalamin that is required for production of hemoglobin.

Methylcobalamin deficiency is associated with specific neurological deficits. So treating with methylcobalamin alone is likely not sufficient, when adenosylcobalamin has the more important role in energy and hemoglobin production. “methylcobalamin addresses ONE very specific aspect of B12 deficiency, and cyanocobalamin converts to the TWO bioactive forms of cobalamin, and if you use methyl, you are using just one that is unresearched and unproven in cats, and gambling that that is good enough.”
http://www.ncbi.nlm.nih.gov/pubmed/10730193

https://books.google.com/books?id=NmziBQAAQBAJ&pg=PA91&lpg=PA91&dq=why%20is%20cyanocobalamin%20used%20for%20GI%20disease&source=bl&ots=MYXEinS-hi&sig=oawimL0mZWM_cOuC0okqdt-OLKo&hl=en&sa=X&ved=0ahUKEwjWqJSDuNnJAhVKVz4KHbz7CDo4ChDoAQglMAI#v=onepage&q=why%20is%20cyanocobalamin%20used%20for%20GI%20disease&f=false

http://www.ncbi.nlm.nih.gov/pubmed/25820384

Vitamin B12 is found naturally in food sources (principally animal products) in protein-bound forms. The body cannot produce it; it can only store it. The human body has roughly a 3-year supply of B12 and 30% of that found in food is typically destroyed by cooking. Over-processed pet food could be a possible culprit in a lot of these deficiencies, dry food being the worst of the offenders.

Feeding your cat a vegetarian or vegan diet is a death sentence, plain and simple. They are obligate carnivores and the only way to obtain B12 naturally in their diets is through meat. Plants and vegetables do not have much B12 at all, if any. Substituting B12 through vitamins for the purpose of feeding an unnatural diet won’t work. They can only absorb so much of it and they have to convert it. And we are now finding out that most pet food labels are not all that they seem and are not revealing all the ingredients and/or proteins.

B12 injections are illegal to obtain here in the U.S. without a prescription and it might be tempting to go ahead and give your pet a dose of the human version or one that is mixed without a prescription. But I wouldn’t recommend it. The human version may contain more preservatives and if it’s obtained without a script, it’s most likely counterfeit B12 and mixed with who knows what. It may contain toxins of some kind and not even the proper dosing of B12 at all which may lead to you inadvertently putting your pet’s health further at risk.

It’s also been questioned as to whether giving B12 masks the symptoms of diseases and malabsorption syndrome. It used to be thought of that dosing anyone, human or pets, with B12 without testing would not cause harm. But the problem is there are other more serious health conditions your pet can have that can produce high levels of B12 indicating those conditions. Supplementing without a deficiency may in fact mask those conditions such as cancer and hypercobalaminaemia. It’s not as rare as you think to discover high levels of B12 especially in cats with lymphoma present that has not been biopsied.

More studies need to be done and until we have more facts, I recommend your cat be tested for a B12 deficiency first and the dosing left up to your vet, just to be on the safe side. But this should NOT deter you from having your cat tested and treated. A B12 deficiency is serious business and can cause a great deal of serious health concerns.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385855/

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