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Author Topic: New Hyperthyroid diagnosis  (Read 2621 times)
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rbauer
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« on: April 05, 2019, 06:07:18 AM »

Dear Itchmo forums,

My 12 year old kitty was just diagnosed with hyperthyroidism on a wellness exam and confirmed with a second more sensitive thyroid test.  It just started.  Wasn’t there last wellness exam.  Only thing changed was a new prescription food that had beet in the ingredient list so I am suspicious that caused it.  The vet wants to put her on felimazole twice a day but I am a little concerned about side effects.  Is it pretty safe?  Also can it be stopped/started easily or tolerate missed doses or does the cat get very dependent on it once you start it and stopping or missing doses becomes dangerous? I read about I131 therapy and am thinking I should start the felimazole now and then maybe in 6 weeks consider the i131 therapy.  Any suggestions or recommendations? Not looking for veterinary advice of course, just maybe some personal experiences?  

Thanks.
« Last Edit: April 05, 2019, 08:59:30 AM by rbauer » Logged
ranger
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« Reply #1 on: April 05, 2019, 11:28:47 AM »

I'm on my third hyper t cat, one did not do well on the meds and did have the I 131. Second did great on the meds. Third has more issues going on right now.

If your kitty can get the iodine I would do it. There is a great hyper t group on facebook https://www.facebook.com/groups/157328711082932/ highly recommend it.

If you start meds make sure to start on a low dose of 1.25 mg twice a day. Some vets start 2.5 twice a day or higher and there were some deaths from that dose.
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rbauer
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« Reply #2 on: April 05, 2019, 11:46:47 AM »

Very sorry to hear about your kitties Ranger.

The vet prescribed 2.5 twice daily. 

The local university veterinary hospital offers an I131 program.   I have to make an appointment with their internal medicine department first and transfer all her records.

Wondering now if it’s worth even starting the medicine or just going straight to the radiation therapy.   Her value was just slightly above normal.   I don’t know how much damage the disease causes if it sits there for a month or so untreated waiting for an appointment at the university hospital.


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Fizzy1
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« Reply #3 on: April 05, 2019, 06:32:30 PM »

Very sorry to hear about your kitties Ranger.

The vet prescribed 2.5 twice daily. 

The local university veterinary hospital offers an I131 program.   I have to make an appointment with their internal medicine department first and transfer all her records.

Wondering now if it’s worth even starting the medicine or just going straight to the radiation therapy.   Her value was just slightly above normal.   I don’t know how much damage the disease causes if it sits there for a month or so untreated waiting for an appointment at the university hospital.




PLEASE do not give 2.5 twice daily.  All of the hyperT forums I've seen say that is too high to start with.  Mandycat should chime in, I think she's associated with the yahoo hyperT group.  Here is my own experience.  Kozy had elevated thyroid level, in the gray area, last September, he's 12 years old and thyroid has been normal prior to this.  We started him on just 1.25 once a day because he had other symptoms such as weight loss.  A month later we had to discontinue the tapazole because he had a reaction to it, with open sores on his face.  We waited for more than a month to re-test to make sure the Tapazole was out of his system and his thyroid level was back to normal.  We re-tested in another month and it was still normal.  I can't explain the one elevated test, but just want to caution you not to do the radiation until your cat is tested a few times to check to see if the original test is valid.  We were ready to schedule the I131 after he reacted to the med, and we would have put him through it for no reason if we hadn't kept testing!

I'm sorry you and the kitty are going thru this!  If she is indeed hyperT, then the iodine is the best treatment for a lot cats, if you can afford it up front.  We would have done this if Kozy had a definite diagnosis, since he was allergic to the med.  The experts don't have a definitive cause for hyperT, but I would really doubt that it was from the new food?

Good luck to you and your kitty!! Kiss
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
rbauer
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« Reply #4 on: April 06, 2019, 04:19:53 AM »

I haven’t started the med yet.  Don’t know if I even should until I retest.  Do most kitties tolerate 1.25 mg twice daily just fine or do they all start having side effects to this medicine like no appetite and vomiting or worse?   And is it okay to cut the coated pill in half with a regular pill cutter and hide it in a pill pocket?  Thanks.
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Fizzy1
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« Reply #5 on: April 06, 2019, 06:09:50 AM »

Yes, you can split the pills with a regular pill cutter and pill pockets are fine to use with the med.  AFIK, 1.25 2/day works well for kitties.  I think the retest should be done no sooner than 3 or 4 weeks after starting, and you might then need to increase the dose at that time but again, go slowly.  I don't know about the side effects, but if the hyperT diagnosis is correct, then you must give the meds or do the I131.

Mandycat has a great deal of info for newly diagnosed here:  http://itchmoforums.com/feline-hyperthyroidism/feline-hyperthyroidism-basics-t14414.0.html

I didn't answer your earlier question about whether waiting for a while on the I131  will cause more problems, sorry!  Unless the cat is extremely far along in the disease, it's not likely to make a difference, IMO.  It is a progressive disease but it occurs over a long time.

Do read Mandy's link, though.  I haven't read it thoroughly in a while and may have missed something.  Hang in there!   Smiley
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
Fizzy1
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« Reply #6 on: April 06, 2019, 06:40:24 AM »

Also, I think generally speaking that most cats tolerate the pills but if not, a transdermal med is available.  It’s a gel you would apply to the bare spot near her ear.  Catbird and others have used it.
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
rbauer
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« Reply #7 on: April 06, 2019, 11:33:19 AM »

Fizzy1, I’m really grateful for all of the help, advice, and links to resources that you and ranger have shared.  Thank you so much.  I keep staring at the medicine bottle but probably should start the 1.25 mg twice daily tomorrow or Monday then for sure - before she loses any more weight.  I’m a little uncomfortable not following the vets instructions exactly, but it seems like it’s better to start slow, and if there’s any problems they will be less severe.  The cat should have some kind of beneficial response based on what everyone’s saying.  After the recheck I can always titrate upward if tolerated.   I don’t think the vet will be upset for not following her instructions, especially if 1.25 does the trick.  I just saw that the pharmaceutical company actually has a coated 1.25 tablet now, but only available in Canada and UK, so that lends some weight to this discussion as well, or why would they even invest in producing that.
« Last Edit: April 06, 2019, 11:39:38 AM by rbauer » Logged
Mandycat
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« Reply #8 on: April 06, 2019, 05:20:55 PM »

rbauer,
My thanks to Fizzy for giving you the information I would also have given you.  She is correct that you should only start the Felimazole at 1.25 mg twice a day with doses 12 hours apart,especially if the T4 was only slightly elevated.  Actually, I would like to know the actual T4 result.  There are certainly instances like Fizzy described where a T4 test result can be slightly elevated but the cat is not really hyper-t at all.  To try to confirm the diagnosis, the vet should palpate for an enlarged thyroid nodule, and symptoms are very important, especially weight loss despite a ravenous appetite.  If the other test you had was a Free T4, that is no longer considered to be a reliable confirmation of hyper-t since it is frequently elevated when a cat has other non-thyroidal medical issues.  It is not very likely that the beets in the new food would have caused hyper-t. 

The pills are generally safe, but can cause side effects in some cats.  The most common side effects are GI in nature, so loss of appetite, vomiting, diarrhea may occur.  However, if the dose of the medication is too high and the T4 decreases too much, those same side effects can occur.  So, retesting the T4 3 weeks after starting the pills is recommended so you can see if there is a need to increase or decrease the dose.  Not all cats will have side effects, especially with the low dose.  It is necessary to dose consistently every day to keep the T4 in the ideal range, which is 1.5-2.5 ug/dL or 20-32 nmol/L, depending on which unit of measurement your lab uses.  These values are equivalent - just different units of measurement.  It is always safest to start with the 1.25 mg twice a day and increase if necessary to prevent the T4 from decreasing too much and causing hypo-t which can have an adverse effect on the kidneys if prolonged. 

The I131 treatment is the gold standard for treatment since it is a cure rather than a control.  Some facilities will want a trial of  the Felimazole (methimazole) before doing the treatment to be sure that there is no serious kidney disease because  hyper-t can mask underlying kidney disease which is unmasked when the T4 normalizes on the medication.  If the T4 is borderline, you would also want to know for sure that the kitty is truly hyper-t since doing the I131 treatment on a cat who is not would destroy their thyroid totally. There can be false positives on the test, so borderline results need further confirmation.  The most definitive confirmation is a test called a thyroid scintigraphy scan which allows for visualization of the adenoma (benign tumor) that causes the condition.  It is not widely available, but is very helpful if it is available in your area if a diagnosis is needed sooner rather than later.  If you have a treatment facility in your area that you would be considering, I may be able to give you some feedback on that facility as far as their protocols and availability of such a test if you post that name.  The support groups can also help with that.

There is a learning curve for managing this disease, so I do recommend that you do some reading about the disease and join a support group.  The facebook group is a good one and was actually founded by the same people who are on the Yahoo Hyper-Y Group that I am a member of.  The Yahoo Group can be found at
                 
                    https://groups.yahoo.com/neo/groups/feline-hyperT

I think I gave some links to the websites of Dr. Mark E. Peterson in my link here on Itchmo.  Dr. Peterson is a veterinary endocrinologist who is considered to be the foremost expert on feline hyper-t and is the one who first described it in 1979.  There is lots of important information you can read on his websites.

Although everything may seem to be overwhelming right now, it does get easier once you are familiar with the disease and its treatment.  I had 2 hyper-t kitties.  One was managed with the medication for 5 years until she passed away at age 20 from an unrelated medical issue.  The other had the I131 treatment and it was very successful.  She also passed from an unrelated medical issue. 

I know that this is a long message, but I hope it helps you with your decision and with obtaining further information you may need to treat your kitty.  Keep us updated.
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Mandycat
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« Reply #9 on: April 06, 2019, 05:28:29 PM »

rbauer,
To add to my previous post.  I looked back at my thread here on Itchmo, and at that time, the Free T4 was still considered a good confirmation for the hyper-t diagnosis, so you will see that there.  However, that has changed in recent years and it is not considered so reliable now.  Here is an article by Dr. Mark E. Peterson that discusses why an elevated T4 and/or Free T4 are not always diagnostic for hyper-t.  I am not saying that your kitty is not hyper-t, but just making you aware that you need to be cautious when the T4 is borderline high or still within the high end of the reference range.  I don't know your T4 test result, but this information may be helpful if there is any doubt.

                   https://animalendocrine.blogspot.com/2013/08/is-high-serum-t4-or-free-t4-level.html

             
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Fizzy1
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« Reply #10 on: April 06, 2019, 06:12:47 PM »

Fizzy1, I’m really grateful for all of the help, advice, and links to resources that you and ranger have shared.  Thank you so much.  I keep staring at the medicine bottle but probably should start the 1.25 mg twice daily tomorrow or Monday then for sure - before she loses any more weight.  

You are very welcome.  I know how overwhelming it can seem, but all you need to do is take it a day at a time. 

Yay, Mandycat is here!   Smiley
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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
rbauer
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« Reply #11 on: April 07, 2019, 05:56:56 AM »

Hi Mandycat, thanks for providing all of this great information.  There is so much to learn and I'm really grateful for all the help and support that you and everyone has been providing.  You had asked a few questions in the previous message.  I'll try to fill in as much additional detail as I can.

1) There is a second ongoing illness that's complicating things.  A bloody nose, inability to chew dry food and dropping it at the bowl, along with pain behaviors (hiding, rigid stance, etc after eating dry food) is what brought her into the clinic initially. They noticed a very angry carnassial tooth.  Blood labs were taken and were normal except for the borderline T4 (confirmed with Free T4).  Urinalysis revealed blood and crystals.  A decision was made to place her on Clavamox tablets for 7 days and Buprenex every 12 hours or as needed.  She made it to day 4 okay on Clavamox but got diarrhea early on, which somewhat improved with giving her Benebac.  She's vomited the last couple doses, and has started vomiting meals and lost her appetite.  I'm having to hand feed lunch meats and coax her to eat.  I don't think I can finish out the Clavamox - her tummy is too upset now and maybe I should stop it.  What do you think about stopping it, halving the dose, or asking them to switch her to Metronidazol?  This not eating well is not good.  They won't do the dental and extract the tooth until about 4-5 weeks from now when they want her T4 to be normal.  I don't understand- I feel she needs to get back to eating normally and the sooner that tooth comes out the better.

2) The most visible Hyper T symptom was weight loss. She was 14 lbs in September 2018, but only 12.5 pounds on Tuesday. No real diet changes except adding Royal Canine gastrointestinal energy dry to her other dry food between the September and Tuesday vet visits.  She had good blood labs before but she had been drinking a lot also and frequently scratching at her neck.  She also had frequent 4 am vomits that were somewhat corrected by feeding later in the evening but it still happens occasionally - like this morning.  I've been awake since 4 am with her, she threw up, refused breakfast, etc.

3) The nearby hospitals that do I131 are University of Penn (Penn Vet) which is close to me, or VSEC in Levittown.   I e-mailed the Dr. at the Penn program and was advised to make an appointment with internal medicine first and let them get her records and refer her to the program.   After reading more I have become concerned that if I start the Felimazole it might change her perfect liver values and she'd be disqualified from the I131 program, or it may unmask a kidney problem that would also be disqualifying.

4)  I emailed the vet and asked for all the lab reports and will post them here or send them to you via private message on Monday.

Right now I'm just trying to get as much food into her as I can with frequent hand feedings.  Not sure about continuing clavamox at full dose.  She threw up this morning's dose anyway and there's only two days left to go.   Also not sure about starting 1.25 Felimazole now until she's eating normally again.  If she develops an aversion to pill pockets from vomiting it will be difficult to pill her in the future.  The vet's office is closed until tomorrow.   Gosh things are so complicated.   Any thoughts or advice greatly appreciated.  Thanks.  
« Last Edit: April 07, 2019, 11:02:38 AM by rbauer » Logged
rbauer
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« Reply #12 on: April 07, 2019, 07:50:17 AM »

Also just bought some high calorie nutritional gel to syringe into her mouth a few times a day until the appetite is back to normal.
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Fizzy1
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« Reply #13 on: April 07, 2019, 03:28:26 PM »

Rbauer, I hope Mandycat will post some answers for you.  I don’t know what to tell you about the Clavamox.  It’s so hard seeing them with no appetite, and vomiting.  The nutritional gel is a good idea.  When you speak to the vet you might ask about an appetite stimulant.  I don’t like their side effects, like lethargy, but it might help get her over the hump here.  Not trying to give medical advice, but I prefer giving 5mg of Zyrtec for appetite stimulant, instead of the prescription ones.  Zyrtec seems well tolerated by cats and it does have the app. stim. effect, but it’s used off-label and some vets aren’t up to speed on it.

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I once asked a four year old what the secret of life was.  "Feed the kitties," she said, "Feed the kitties."--Ellis Felker
Mandycat
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« Reply #14 on: April 07, 2019, 05:50:30 PM »

rbauer,
It would help to know the exact T4 test result.  Also, as I said previously, the Free T4 is not now considered a reliable confirmation of hyper-t, especially when there is also a non-thyroidal medical issue.  Obviously this is the case with your kitty, so the Free T4 result may not have confirmed hyper-t.  It appears that the weight loss may be the only hyper-t symptom.  However, could that be due to the dental problem?

Clavamox very often causes diarrhea in cats.  If that were the only problem, I would say finish the course of it.  However, if there is vomiting, your kitty is probably not getting the full benefit of the antibiotic anyway if it is coming back up.  I think I would ask the vet about changing the antibiotic if he thinks she still needs additional medication for the problem.  As for waiting for the T4 to be normal before doing the dental, there could be another reason, like a question about her kidney function status, that is making them want to wait.  Vets don't like doing anesthesia if they think there may be a kidney disease issue.  I would have to also know the BUN and Creatinine test results to determine if that could be an issue.  I agree, however, that, if there is no possibility of underlying kidney disease and the T4 is just very borderline, it would seem to be better to just get the tooth out.  Perhaps the vet would reconsider if he knew that she was not eating which could make her sicker.

Fizzy's suggestion of using Zyrtec (cetirizine), which you can buy over-the-counter as an appetite stimulant is very good.  It is used by many cats on the Yahoo Hyper-t Group when they have appetite issues.  The usual dose is 1/4-1/2 of a 10 mg tablet (2.5 - 5 mg) once a day.  It does not have side effects like the prescription appetite stimulants.  However, if the cat is also nauseous, you may also need an anti-nausea medication for best results.

Do not worry about any liver issues if you decide to start the Felimazole.  That side effect is extremely rare.  In fact, the truth is that frequently cats will have elevated liver enzymes when first diagnosed with hyper-t, but it does not indicate any true liver disease.  It is just a symptom of the disease and the liver enzymes return to normal once the T4 decreases and the hyper-t is controlled after treatment.  So, if your kitty has good liver enzymes now, that is actually something that could indicate that she is NOT hyper-t, or that it is so early in the course of the disease that they have not yet become elevated.  I have never known of a cat who could not have the I131 treatment due to any elevated liver enzymes.  I previously said that hyper-t can mask underlying kidney disease which would be unmasked with treatment as the T4 normalized.  The kidney disease would have to be very severe to disqualify a cat from having the I131 treatment.  Some vets still like the do the methimazole trial to see the results of the kidney values when the T4 is normal, but, unless the kidney values were already very high before starting the medication, it is unlikely that kidney disease severe enough would be unmasked.  The T4 and the Creatinine tests have an inverse relationship.  When the T4 is elevated, the Creatinine is suppressed; when the T4 decreases, the Creatinine increases.  Very often the Creatinine just increases and decreases within a normal range, but can also increase enough to unmask underlying kidney disease in a  hyper-t cat.  Most of the time this underlying CKD is very mild, and has no effect on doing the I131 treatment.

I don't know if UPenn has the ability to do the thyroid scintigraphy scan, but they might since they are affiliated with the university.  I would ask them about that since they may include that in their protocol for doing the treatment and it would definitely confirm the hyper-t diagnosis when the T4 is borderline.  You might want to follow through with submitting her records and have her evaluated for the treatment.  But, even if they don't require a methimazole trial, they would probably want the dental problem resolved before doing the treatment, and your vet won't address the dental problem without giving the medication to decrease the T4.  So, you do have some issues to resolve with that.  

Cats can have problems with acid in their stomachs that cause middle of the night or early morning vomiting due to long stretches of time without food.  If this could be the problem with your kitty, the suggested treatment is to give 1/4 of a 10 mg tablet of famotidine (Pepcid) at bedtime along with a small meal.  Smaller more frequent meals during the day also helps.  This may not be the current problem, but sounds like it could have been the problem in the past.

If I am able to see the lab results, I may be able to be a little more specific in my comments.  I don't want to mislead you, so these comments are pretty general without knowing any numbers.

As you are gathering information about the I131 treatment, ask UPenn if they tailor the dose of I131 to the individual cat.  I didn't find that information on their website.  It is important since you definitely don't want a one-size-fits-all dose given that would result in more possibility that she would become hypo-t after the treatment.  VSEC does appear to tailor the dose according to what I read on their website, but would want to verify that also.  Your choice of facility for the treatment could depend on that answer.
  
« Last Edit: April 07, 2019, 06:03:46 PM by Mandycat » Logged
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