Hi, everyone. Welcome to tonight's webinar. Thank you very much to Dera and Webinar vet asking me to join you this evening.

My name's Sam Taylor. I'm a feline specialist working in the UK and I work for ISFM, the International Society of Feline Medicine, as well as working for Lina. So what are we gonna talk about?

Well, obviously we're gonna talk about eating. And I just quite like this quote that I've put on here, how we can't think well, love well, sleep well if we haven't dined well. And I guess I want you to remember that because eating affects so many things for us, but also for other species.

And therefore, if our, feline or canine patients don't eat well, then they can't do everything else well. So in this talk, what we're gonna discuss is sort of eating and why we worry about inappetent. I want to talk to you a little bit about nutritional assessment.

We're gonna focus in on hospitalised patients. We'll cover appetite stimulants and we'll also discuss feeding tubes and when it's appropriate to use them. And our take home message that I want you to go away with really is not to wait and don't hope they will eat tomorrow instead intervene earlier and act today.

So let's interweave into this talk a couple of cases, because I know I always find it helpful to think how we apply some of these concepts to cases. And so we've got a couple of cats for you. We've got Rex first of all, and Rex is one of those cats that you can sort of see him from the waiting room.

He's so yellow, so he's a very, very jaundiced cat. He's a 10 year old man used to domestic short hair with a pretty otherwise uneventful history. But his current problem is 2 weeks of inhapetence, and for the last 3 days, his owners tell us that he's eaten absolutely nothing at all.

He's been treated with some amoxlav, which didn't help. And this jaundice that's now quite severe, it wasn't as bad a week ago, but it's been progressively worsening. He's been now referred, and that's where I saw him for further investigation.

He has lost weight and his current body condition score is 3 of 9. So remember some of the sort of aspects of this case, and we'll apply it a little bit later when we talk about nutritional assessment. Got another cat for you here, and this is the kind of case that if you're into feline medicine or medicine full stop, you could find quite interesting and exciting.

If you're a surgeon, you probably, want to turn away right now when I tell you the history, because this is quite a complex case. Princess is a 13 year old female neutered domestic shorthair. She has a history of chronic kidney disease and she also had an episode of urethral obstruction which actually necessitated her having surgery and a subplaced.

Now what a sub is a subcutaneous ureterral bypass device, so, bypassing the urethral obstruction and taking urine directly from the renal pelvis to the bladder. Now, unsurprisingly, her kidneys didn't come out of this completely unscathed, and she also has a diagnosis of IRis stage 3 chronic kidney disease. We've had issues with her since this time of that diagnosis and that surgery, being hypokalemic and actually currently her potassium is quite low.

And now, to top it all, she's had a diagnosis of congestive heart failure. We've, we've assumed that that's due to hypertrophic cardiomyopathy, which was then confirmed on an echo as you can see in this image. She needs to be treated with diuretics, but obviously that worries me with her kidneys and her low potassium already.

Nutritionally, she's been picky with food for the last couple of days. Importantly, also to consider she's difficult to medicate. Her weight's stable.

She hasn't lost any weight at this time, but her body condition score again is only 3 out of 9, so slightly reduced. All right, so keep those cases in your mind as we move through our talk. I just want to give you a shameless plug now that's gonna give you a lot of background on inhabitant cats, nutrition, medications, dosages, and then finally about the placement and use of feeding tubes.

And that's our ISFM guidelines that we created in 2022 to really help primary care clinicians in the management of this particular condition. So, I've got a QR. Code for you there, but you can also just Google these and find them.

We've got our guidelines with, as I say, all the doses, but we've also got some information for owners and some videos for both yourselves, but also, again, for owners who are using esophagostomy tubes at home. So I hope you might find them useful. Let's talk about cats and nutrition.

Let's go back and and sort of start from the beginning there. Well, you and I both know that cats are not small dogs. I'm sure I don't need to teach you that at all.

So let's think about some of those differences. Well, cats are strict carnivores, we know that. They have got a high protein requirement and one.

So a slight design flaw in that for cats is that they don't adjust that requirement according to intake. So if their protein intake drops, then they will compensate for that by digesting their own muscle to meet those needs. And then we're going to talk about, actually in this talk, some of the differences between sick cats and healthy cats when you talk about nutrition.

And one of those things is that sick cats actually have an even higher protein requirement. They may have extra losses due to illness, they may have inflammation, and all of these things contribute to that increased protein requirement. Essentially cats are not designed not to eat.

They're designed to eat many small meals a day, so think of them eating mice, eating birds and eating 15 different small meals a day, rather than having any periods of fasting. So what happens in starvation? What happens when cats don't eat?

Well, as I mentioned, the requirements of protein are different between health and disease and actually starvation and the effect of fasting is also different between health and disease. So simple starvation, if you took a healthy cat and they didn't eat, they would have compensatory mechanisms to a point of glycogenolysis and gluconeogenesis, if you remember your pathophysiology, so they would be maintaining their blood glucose and their energy, meeting their energy requirements through these processes. The problem is when you're, you're stressed or you're ill, so what we call stress starvation, so when you're hypermetabolic because of your illness, and as we mentioned, those inflammatory processes, then you can have actually increased proteolysis.

So that lean tissue loss is accelerated. To put it into a diagram, because I quite like to look at a diagram, it seems to help my brain absorb the information. Let's think about this.

We've got our our fasting and therefore depletion of glycogen stores, and what cats will do is they will use fats as an energy source that can cause its own problems when we think about hepatic lipidosis. We also, as mentioned, get the process of gluconeogenesis, which will eventually result in proteolysis from muscles once those glycogen stores are depleted. Add in illness and inflammation and some of the hormonal changes as a result of that, increased norepinephrine, for example, with the, the stress of illness, cortisol, etc.

Etc. And that feeds into that process. The result of proteolysis and fasting in sick patients is obvious things like weakness and eventually sarcopenia and frailty, but also things like poor wound healing, immune dysfunction can affect even gut wall health.

And what in the long run that means is a poor prognosis. So actually fasting has, you know, sounds like a a simply a cat not eating, for example, post surgery or due to illness, but it really can affect their prognosis for recovery. Other consequences of not eating, well, obviously we know about hepatic lippidosis, we're very aware of that, but we can also get things like dysbiosis and we're all very aware of the importance of the GI microbiome these days.

Cats are not very brilliant at drinking, and so not eating will often also result in dehydration because they will get water from food. And also sometimes there's a pattern in some cats behave of, of drinking after they eat. I don't know if you've seen your cats do this.

So therefore, if they're off their food, their actually water intake will go down. We might get electrolyte abnormalities such as hypokalemia, which will then perpetuate that inhabitant, and things like constipation is something you may not think about, but a dehydrated cat is more likely to become constipated, add in pain and illness, and we've got even more likelihood of that, and that can make cats obviously not want to eat and feel unwell so we can get a vicious cycle. OK, so that's the consequences on the cat.

What about consequences on the owner? Well, you're probably thinking, well, what are you talking about? Why would poor nutrition have any impact on owners?

But actually it does. You all know your your experienced, veterinary professionals, that the owners will often equate food intake and eating with health. And they find it distressing when the cats don't eat and they perceive that as poor health.

We all know those cases of of cats that are very Very unwell, but owners will say, but he's still eating, he can't have X, Y, and Z. And it won't be until they stop eating that they're presented to the clinic on on some occasions. Owners may be sort of tolerant of other clinical signs, but as soon as they stop eating, that might prompt them to seek veterinary attention.

But equally, I want you to think of a few other knock-ons. Now cats that are not eating are really difficult to medicate, and it's not infrequent for us to see a cat with a poor appetite and want to obviously give them medication for their underlying disease, but this can leave the poor owners in a situation where they've got to give medications they don't have the option of giving it, for example, in treats or in food. That can be really problematic.

Owners can also become really anxious, as we said when the cats don't eat. But equally they can get frustrated with us as threatening professionals and dissatisfied with the with the treatment, even if perhaps the underlying disease is improving. Their perception of improvement may be weighted with appetite.

It could actually have knock-ons as far as owners declining, for example, further workup if they perceive their cats as not responding to treatment or becoming more unwell or their appetite not improving. And therefore, it's possible also that a lack of appetite simply could lead to accelerated euthanasia decisions because of this perception of success of treatment, and this is all tied up with sort of the psychology of feeding our pets and and wanting them to be wanting them to, to feel well and have an appetite and, and actually what we as owners get in reward for seeing our cats eating, it sort of makes us feel good when we feed our, our pets. So there's, you can see it's sort of almost more complex than just our own frustrations of our patient not eating.

And actually it really matters if we, if we look at the evidence base that we have. I'm not looking specifically at appetite here. I'm looking at the results of poor appetite, and that's poor body condition.

And we have some studies here really showing if we look on the right of the slide, we can see that actually, emaciated cats and lean cats have a poorer survival than cats in optimal condition. So we've got a survival curve here, and every time it drops down, that's a cat that's dying. If it reaches the bottom, then all of the patients in that group have have died.

And what we can see is that the thinner cats essentially have higher risks of death, and we can see this, on the chart, table I've got below as well, where emaciated cats have a much higher, mortality rate. And on the left, we have a study looking at all different body condition scores in cats. And what we can see is that again, Using this type of survival curve, the, the ones that drop down the soonest, are the cats in poor body conditions.

So in maximum body conditions score of 3 in this situation, and then we've got the 4s following after. OK, so really interesting. The next one actually we can see having an effect is, is cats with body condition score 9.

So clearly that's also not desirable, but it's certainly the skinny cats that have the shortest survival. And that's been looked at also with various conditions and interestingly the same is true of humans and it's something that's been studied in older humans. But in cats, we can see in studies of chronic kidney disease, hyperthyroidism.

And lymphoma that cats in poorer body condition score have have a reduced survival. So we can see the lymphoma cats here, cats with a body condition score of less than 5, having this, this quicker downward curve than cats with body condition score over 5, and lighter cats using weight rather than body condition score in this study of cats with chronic kidney disease, having a a a significantly longer survival if they are a higher body weight. OK, I told you I was gonna talk to you about nutritional assessment, and whenever you discuss this, I can almost hear a collective sigh because it doesn't sound very interesting for a start.

And it also might sound er very challenging to do in primary care when you have short appointment times and you're extremely busy and you've got a lot of cases and a very high throughput of cats and dogs going through your clinic. Actually, the WSAVA consider nutritional status and nutritional assessment as the fifth vital sign behind your temperature, pulse respiration when we've got pain assessments, and then we can add in nutritional assessment as part of a, a full, you know, overall assessment of our patient's health. Now, this type of nutritional assessment is important more so in hospitalised and critically ill patients and in primary care it's not something you're going to be doing on every case.

What I want you to think nutritional assessment as is basically just simply a a kind of a screening process to identify cats that need your attention more from a nutrition point of view. So this is kind of irrelevant to their underlying disease. So what you do is when you're approached with a case, you think about whether you have risk factors for their food intake really and their nutrition.

And then you've got a whole other group with no risk factors. So clearly you vaccination, routine neuring, etc. Etc.

Falls into this, no risk factors. But once we add in illness, poor body condition, etc. Etc.

We move into a situation where we have got nutritional risk factors, OK? And those patients would therefore benefit from more attention to their nutrition and further assessment. So it's really to me, enabling you to detect the red flags of when we need to look at, look at this.

And in our guidelines, we've got a, a sort of chart for you here, which I've reproduced on this slide, which again just shows you how to assess this, this risk. And some people quite like tools and, you know, sort of being able to quantify risk. Other people, you know, this is just adding, adding steps, but probably these are things that you'll do kind of in your head as you're assessing a case.

And so it's still useful to have a look at them. And what we can see are the red flags are reduced food intake, so less than 80% of resting energy requirements for more than 5 days. We've got severe GI signs, poor body condition, poor muscle condition.

So that's again something we can talk about, but not just an assessment of sort of weight and body conditions, but actually what's happening to their muscle quality. We've got other things like expected course of illness being longer than 3 days. So if you think of many patients that we see, we're not going to cure them within, within a couple of days.

So it might be that their expected course of illness is really gonna influence their nutrition. And then we can say that if we have more than 2 high risk factors, those patients are gonna need probably feeding tubes and quite intensive support, whereas actually if they have less than 2 of the high risk factors, then we can plan a reassessment and keep an eye on them really. So let's apply this to our patients that we've talked about just so I can show you that it has got some practical, you know, utility.

It's not just a time consuming. Process, it's something that can really help us with decision making. So if we look at Rex, we know he's had a poor food intake for more than 5 days, so that's a high risk category.

He's had some weight loss. That was a moderate risk. His body condition score is reduced.

It's a high risk red flag. Muscle condition score is reduced. So again, giving us a high risk factor.

And in a cat that is this unwell and this yellow, we're not gonna cure. Within a couple of days. That puts him again into high risk.

So we've got quite a few high risk factors here. We can conclude that he's at high risk of malnutrition and the negative consequences of that. So he requires our support as soon as he's stabilised.

And by stabilise, we're thinking about things like fluid volume deficits, management of pain, etc. So those very, very early steps we will do, but then we're going to intervene quite quickly. Contrast that with princess, and she's had poor food intake, but only for a couple of days, so that doesn't put her into a high risk factor.

She, her weight seems to be stable so far. She has got a reduced body condition score, so we've got one kind of tick there on our risks. Her muscle condition score is mildly reduced, and with her conditions, chronic kidney disease, congestive heart failure, we're not going to fix her immediately.

So we have got another high risk factor. So we've got 2. So we're in that kind of borderline area where she may require support.

It's something we don't want to ignore, and we may need to intervene, but it's a don't do nothing. So I hope you can see that by looking at those risks, we've, we've really added that assessment to our other treatments, and that's gonna hopefully improve the outcome. So here's another question for you.

Are you monitoring nutrition in your hospitalised patients? Well, you know, it's, again, we talked about the how busy we are and the pressures on, on particularly primary care practise. And so these things can sometimes get, get lost very, very easily.

And actually, even in, in referral centres I've seen this get lost. And what I mean by that is not record what cats should be eating and what cats are eating. OK?

So it means calculation of energy requirements based on this resting energy requirement equations, and it means converting that to grammes of food and thinking about how much they should be eating, and then considering their underlying diseases. And I put on this slide about illness factors, and we'll mention this again in a moment. It's something I was taught when I was in college, which is just a couple of years ago, .

That, depending on the illness, we would add more calories in. And we now know that that actually can be quite detrimental, and that's been looked at in a lot of detail in human patients that we should feed for their current body weight. And that may sound odd to you because you think, oh well, if I've got a patient who's very, very thin, then obviously I want to feed them for their weight.

I want them to be. Actually, that could risk overfeeding. And quite a lot of negative consequences.

Sadly, a lot of that research from sort of anorexic people and people who are being fed, when they're very, very underweight. So we will correct that, but we'll correct it a little bit later. We're not going to correct it in this initial period of illness.

All right. So you can have these type of calculations on your hospital sheets and just routinely calculate them for any patient that's coming in and staying. There is a little bit of research about this which is is quite interesting and I've got a a graph here for you from the study that I've referenced on the slide looking at how often people do nutritional assessment.

And what we can see is that a small group of people do this anytime. This is people in the UK and this is a study published in JSAP. So some people do it, you know, routinely a lot of time.

Quite a lot of people never do it, so a third of people never doing it. And then the majority of people really doing it for patients that are unwell, malnourished or at risk of malnutrition. And that does seem quite reasonable, but there is a little bit of a danger that we'll miss, some patients that are at higher risk without, you know, taking that group of only looking at particularly skinny cats, for example, when we might miss some other opportunities to intervene.

So just to say, you know, this is something that is challenging in practise, but I'll hopefully convince you that it could be useful in that group of patients that we're talking about. Just to say that recording anything is easier if you have hospital sheets that are designed for for good recording. It, it's very easy to miss things if your hospital documents don't facilitate rapid recording.

An example on the screen here, and I've got a QR code where you can download. Some hospitalisation sheets that are designed specifically for cats and include the capacity to record food intake, for example. OK, and these were very kindly given to us to include in our guidelines by Lumbury Park, who created a very intuitive hospital sheet which we edited then, to make it very specifically feline.

So you're very welcome to to download that and modify it for your clinic. Some other time savers for recording and calculating nutritional requirements are to have a laminated chart in your ward, which has the diets fed and the calories per gramme, as I say, facilitating recording, and also things like, taking a nutritional history, we'll talk about in a moment. It's very, very important.

And we've got some sheets on there again with our guidelines that you can just use that owners can fill in while they're waiting in the waiting room. Don't get so annoyed about waiting as well when they've got something to fill in and You know, when you go to hospital, it'd be quite routine to fill in some some details and some surveys and some questionnaires, and these can be huge time savers as far as history taking, and they can even be emailed to owners before their appointments. OK.

So just coming back to our, our, our same calculations. Now what you'll notice is on the first slide I showed you this top calculation. Now, all in all, this is a more accurate, potentially way to calculate energy requirements.

And if you look at using the bottom calculation, which is very, very frequently used for larger patients that can, you can have some difference there and and risk over or under feeding. However, in cats as smaller patients, probably you can get away with using either of these calculations, OK? So modern iPhones tend to have the facility to use these kind of super scripted numbers and, using that type of calculation.

So you can do either, on our hospital sheet example, we have got the bottom calculation. OK? So just to emphasise that we need to record that and we need to consider, as I mentioned in nutritional history.

So what do I mean by the nutritional history? Well, it's something that is really important. Cats are what we call neophobic.

So what that means is they can be quite aversive to novel things, food wise. So if you have a cat that's been fed dry food all of their life and they're hospitalised with you, And you offer them prawns and you offer them chicken, they're going to turn that down straight away. OK, because to them, that doesn't really seem like food because probably even related to weaning times and what their, what they were taught by their mothers as far as textures and tastes can last lifelong.

So taking a nutritional history will allow you to identify which patients you you should be feeding what. Because the other thing is, whilst hospitalised, is not a time that we want to introduce novel diets that we want them to eat lifelong. So for example, the cat that comes in acutely aotemic and unwell, everyone's natural instinct is to give them a renal diet.

Actually, I don't want you to do that. I want you to feed them their normal food while they're hospitalised and while they're recovering, and then later we're going to introduce the renal diet. We all know if we feel unwell and we offer a food or we eat a lot of our food whilst we feel sick, you're unlikely to want to eat that again.

And cats are the same. So if we try to change foods, A, they may not be receptive to that because their appetite is reduced and they're feeling poorly, and B, they could then become aversive to that diet. So take your nutritional history, think about what they're more familiar with and go with that initially, OK?

So what about recording things like weight and body condition score? Well, we did a little bit of a study on this last year where we looked at weight and body condition scoring in primary care practise. And actually, people are awesome at recording body weight, so 95% of consults record a body weight, but only 22.5% recorded body condition score.

And we found a little bit like that other study that I showed you, that people are much more likely to record weight and body condition score. If in the text of that consult they had a term like thin fat overweight, you know, they had a weight loss or weight gain term. Again emphasising that we're more likely to do this process if we we eyeball a cat that looks at an abnormal condition.

Also an interesting finding in this study was that weight and body condition score more likely to be recorded in the morning than the afternoon or out of hours. And we can hypothesise why that might be, for example, people are very, very busy and that busyness builds up during the day and out of hours things are perhaps more time pressured. However, out of hours actually might be a time that was more important for us to record, particularly wait for drug dosing.

So that was an interesting finding. OK, so if you want to have a look at that it's an open access paper, but it just really emphasises that. Not just recording weight can be beneficial for our patients.

What about hospitalised cats? Why do they not eat? Well, there are lots of reasons why cats in hospital don't eat, and that is outside of their direct underlying disease.

So for example, Rex is not going to eat because he's got some underlying, perhaps hepatopathy because of his jaundice. But there are other factors that will play into that loss of appetite, including particularly pain, stress, and nausea. Other things are, I've mentioned before about constipation, dehydration and electrolyte abnormalities.

And then some simple things like the taste of medications, or a direct effect of some medications. Some conditions and some drugs like opioids can result in ileus, which really knocks appetite. Nobody would want to eat if they had a a sort of stomach full of fluid, for example.

So when we're managing a patient with inappetence, we need to think of all of those things. So, obviously we're going to treat the underlying disease, but also I think it is really useful to do is to review the medications that they're on. Now, speaking from a referral point of view, we'll often have patients that are hospitalised for longer periods and they've got conditions requiring multiple medications.

But actually, in referral, we're very, very guilty of this, of, of combining and adding a med and adding a med and adding a med. And in that case, you can end up with medications that themselves have effects on on appetite, also interact with each other and can be unpleasant tasting, which can knock appetite. Stress can impact appetite both at home in the hospital.

And do we have a robust system for identifying and managing pain? We talked about how we may need to deal with ileus and nausea, and we're going to correct all of these other abnormalities too. So because the causes are, are multifactorial, our management needs to be multifactorial too, but I don't mean polypharmacy in that.

I mean thinking of some of these other factors as well. So I've got a question for you. What are you most afraid of?

Well, I don't like heights at all, so this picture makes me feel a bit sick anyway. Maybe you don't like spiders, maybe don't like, I don't know, snakes, something like that. So if you were in a situation of anxiety because of, of fear, would you want to eat would be my question.

So if you offered me my favourite ice cream on the top of this skyscraper, there would be no way that I would want to eat it. And the same if we have our anxious cat in the clinic and we offer them food, then they are less likely to be receptive to eating. So I refer you to our cat and the clinic guidelines and thinking about any cat in your ward, healthy or sick, if they are frightened and anxious, they are unlikely to have a good appetite.

One thing in particular that's very easy and quick and cheap to sort out is making sure that every hospitalised cat has somewhere to hide. That can be a cardboard box or on this image, this is the, the top of a, a litter tray, basically a, a covered litter tray that we adapted to be somewhere to hide. You can buy the cat's protection, cat forts, etc.

So having somewhere to hide can make a big difference and some cats will only eat if they do have somewhere to hide. They're not going to be kind of out in the open where they feel very vulnerable. So have a think about your ward.

We mention nausea, and just to mention some, some drugs and in our guidelines, I'm sorry, I know I'm boring. I keep plugging it, but we do have the doses if that's useful to you. Nausea is not always overtly obvious in cats.

It can be quite subtle, and I want you to assume it's present, really, if you have cats, particularly with pancreatitis, intestinal disease, liver disease, but even some other pathologies, thoracic disease or cats have had surgery or upper respiratory tract disease. There's lots of reasons that people and cats will feel sick. The mainstay that you're gonna use, drug wise is going to be, mropotent, and murropotent is a very effective drug in cats, and it can be given orally as well.

So there are, obviously licenced products for dogs that are given orally, but there are also reformulating pharmacies that can provide reformulated, Robartant tablets that are really nice for cats. Other drugs, things like ondansetron, can be a little bit fashionable to you sometimes, and there are people who quite like the drug ondansetron, but just want to remind you, it has its own side effects. So it causes constipation that can be very, very severe in humans.

It can cause, other, it can knock appetite kind of itself. So sometimes our best intentions actually, can result in some adverse effects of medication. Mestoclopramide is old fashioned, but it still is effective in this species and also has some pro-kinetic effects.

So probably the most useful application of metoclopramide would be at a continuous rate infusion in hospitalised patients, particularly if they also have ileus, as well as nausea. So just a few thoughts on those drugs. OK, and when I was looking and writing this talk, I found that there were actually a plethora of videos on the internet of these poor cats that when they get offered anything, they wretch.

And this was just to remind me and you that sometimes nausea is really obvious, other times it's really subtle. Pain scoring, I'm sure it's something you are doing and you think, why are you talking about pain scoring and an appetence talk, but it's easy to see the connection that painful patients, and also on the other side, dysphoric patients who've been treated with lots of opioid, neither of those groups will eat. And sometimes I think everyone is so, so good at pain management that we can go the other way and not review our pain management.

So what I mean is, I don't want you to avoid giving opioids, absolutely needed for pain. And sometimes there can be a situation where, for example, in surgical patient, they have, or a trauma patient would be another example where they have methadone, but that methadone is just continued for a day too long when the initial trauma and inflammation is, is wearing off and actually switching to buprenorphine, for example, would be appropriate. And those cats can become quite dysphoric.

So it's about sort of assessing obviously for pain and identifying pain, but also reviewing our pain management strategies. Thinking about, for example, regional anaesthesia, which is, is, you know, avoids many of these side effects. So do think about that and I'll just include the grimmest scale, which I'm sure you're aware of, but if not, it is a really useful way of monitoring for pain in your clinic and actually owners can even use it at home.

I, I mentioned polypharmacy and drug effects a couple of times with you now, but just to, to pick out a few things like opioids we mentioned as ileus causing, they can cause nausea, constipation, and we mentioned kind of dysphoria and overstation. Things like omeprazole can have adverse effects on appetite, and then we all know those cats that we've tried to give medication to. Perhaps they crunch the tablet, or we try and give them a liquid, and if it's very, very bitter, be a cat that's foaming at the mouth and hyper salivating.

And if anyone has tasted reniine or metronidazole personally, you'll know these are really horrible tasting drugs and those cats are not gonna eat. Obviously they've got a very, very bitter taste, but it's likely also that that medicating has caused significant stress. So just review those drugs that they're on.

A question for you. When would you intervene? When do you worry about poor appetite in cats?

Is it after 2 weeks of inhapetence, 2 days, 5 days, 3 days? Well, actually, the advice and what we put in our guidelines was 3 days in considering support for any cat that's been eating less than their recommended allowance for 3 days. Now, where does that come from?

Well, actually some of that advice is based on a study that I've got on the slide here. Where, you know, cats were fasted and in those fasted cats, they monitored their markers of immunity. And one of the things that they noticed was that their lymphocyte counts dropped at 4 days, and hence this advice to intervene at 3 days.

It is a little bit arbitrary, but I think it's useful because it shows us as in Nutritional assessment when we need to start worrying. So in the nutritional assessment, we talked about, you know, sort of 5 days and 80% of RER. So you can see some kind of slightly different advice there.

So look at the nutritional assessment, but you can also quite reasonably consider 3 days as a, as a cutoff point. And I'm sure you'll agree that many cats that come to you for illness have actually been eating less than RER for more than 3 days at the time that you initially see them. So what about appetite stimulants?

Well, appetite stimulants can be very useful in the management of hyperorexia. What I want to tell you is that they won't work if we don't control some of the other factors. So if we have a patient that's nauseous or painful, and give them all the mirtazapine in the world, they're still not gonna eat.

And equally some people worry about masking disease with appetite stimulants, so I sometimes get asked, well, I'm worried about using them. I won't know if my treatment's working. I won't know if they're getting worse.

Well, they're not that good, to be honest with you, you know, they're not going to overcome an underlying illness. That's why I'm saying using appetite stimulants at an appropriate time, at point in, in a patient's illness is important to get the, the kind of optimal effect. Also consider compliance.

It's another medication, it's potentially another tablet, . And it's very, very easy, as we mentioned, to add one after another when things are not going our way. So use them at the right time and consider you've controlled other things.

You know those cats that are going up to the food, sniffing it, maybe licking it, then walking away, or they go to sniff it and then there's a noise and they go away and hide again, you know, there's probably feeling quite anxious. So think of those patients where we have got control of as many things as we can control. We might have cats that have had previous episodes of nausea or have been nauseous and then they've been left, that that's resolved, but they've been left for some food aversion, as we mentioned, very easy to, to happen.

So those cats that are taking interest in food or they are eating, but they're not eating enough, they would be the type of of patients that we could consider. And in the UK and many other countries, the licenced appetite stimulant for cats is Mirattas, as we can see at the top here, which is transdermal mirtazapine. Depending on where you're listening from, you might have availability of some other drugs.

And this drug called Entice, Caramelin, that's a drug that has a licence for dogs in some countries. I'm told I I've not used it myself. You can import it into the UK.

It's reasonably expensive and that the, the flavouring, I think, has been designed for dogs, so it has a, some kind of marshmallowy sort of flavour. And people I've spoken to, cats haven't particularly enjoyed that. So let me know if you've had different experience.

So when are we gonna use these appetite stimulants? We've talked about kind of controlling our other our our nausea, etc. Pain, etc.

But what else, what other situations could we use appetite stimulants? Well, very useful as part of chronic disease management. I think they're useful for helping compliance to medications.

If you have a cat that's just not, that is eating but not eating that much and not particularly into treats, for example, we can turn that situation into a cat that will take a medication in, a pill putty or in a liquid treat, for example. It can help with hydration. Sounds silly, but again, we said the cat that's picky with food, they're not getting their water intake that we might, need.

And Another use that I think is, is, well, something I would just urge you to think about. We talked about not introducing diets that we want them prescription diets, for example, that we want cats to eat long term whilst they are ill. But perhaps they've now showing recovery, improving, and we're considering a transition to a diet that they are not familiar with.

So that cat I mentioned to you that will only eat dry food. That cat that will only eat one type of whiskers, where everything else is is going well, you know, they actually their appetite is improving, then using an appetite stimulant can overcome some of that neophobia. And I've used that with some success when converting cats for, for example, GI cases to hydrolysed diets.

And I mentioned food aversion, and neophobia, so it can be useful in those situations. Another use I just want to mention to you is as outpatients. So what some people will do is in their clinic, they will have a tube of Miritas, and instead of charging the whole tube out to clients who are, for example, waiting for blood results in a cat that's just not eating as keenly as they were or has recently gone a little bit off their food.

And what they'll do is they'll charge out a dose of that. So when they, you take the bloods, you apply a dose of Miritaz. And that means that you can then hopefully improve nutrition for the day or so that's gonna take for you to get the results back.

So that remember my, my initial kind of diagram about that, that kind of vicious cycle as well as the owner's feelings about how their cats are doing, you just buy yourself a little bit of time. Other times recovering from illness, recovering from surgery, general support of body condition, particularly in senior patients. We know that taste reduces in senior cats, also with dehydration, for example, from chronic kidney disease.

A drier mouth even can reduce and alter the taste of food, and it sounds silly, but when we look at our older pets that this can happen. So appetite stimulants can help with that too. And mirtazapine, I'm sure you're very familiar with how it works, but you might not be familiar with some of the mechanism of action that also suggests that it has anti-emetic effects.

And in dogs, it's been shown to have some pro kinetic effects too, so. All in all, that, that does make it pretty useful in some of these patients. OK.

Adverse effects are possible, and it's something that owners may need to be aware of. I think we see them less now that we're using an appropriate dose of this drug. And what I mean by that is that in the past we had to use human mirtazapine, 15 milligramme tablets and, and chop them up, and it meant.

A fragment of a tablet that could be a bit of a higher dose. And I think then we did see some restlessness, but I do hear from owners occasionally that they've been a little bit pacey, a little bit agitated after administration. So something to just think about.

Those, those adverse effects will resolve and you can try using a lower dose, on a subsequent occasion or using the drug less frequently. Got a couple of studies here about the use of oral mirtazapine and transdermal mirtazapine in various different conditions. And the take home from that is, regards to kind of safety of the drug, but also increased, food intake, some weight gain, increased activity and less vomiting, which is obviously all good things in some of these, these chronic illnesses.

So do we give our patients that we talked about, let's come back to them. Should we give them some appetite stimulants? Well, Rex, I think, no, we haven't controlled his, we haven't started treating his underlying disease.

We haven't kind of controlled his potential nausea, etc. I haven't done anything else yet. He clearly needs some treatment.

And it's unlikely, given how long he's been, had a reduced food intake for that he's suddenly gonna respond to appetite stimulation and start eating. It would be more appropriate to place a feeding tube and really attend to his nutrition, remember all of his red flags and his high risk factors. We can use appetite stimulants, you know, as he's recovering, absolutely, and alongside our tube feeding, but I don't want to start using an appetite stimulant and delay intervention for another 24 hours.

Princess, different situation. We had less of our high risk factors, didn't we? And it could benefit her regards things like hydration, which clearly putting our CKD cap on diuretics worries us regards hydration and her body condition score.

We don't want more days of her eating less. Would it make her easy to medicate potentially? Could we avoid further weight loss that's gonna send us down that sort of black hole of deterioration?

So we could certainly try. And just a note on some other chronic illnesses that could potentially benefit from nutritional intervention, that might be appetite stimulation, but it might also be other interventions. Things like chronic kidney disease, chronic enteropathies, obesity.

What am I talking about? You probably think I'm crazy, but to encourage again, intake of a different type of a more appropriate food, cats with neoplasia, cats with cardiac disease, etc. And let's move on and just finish by talking about some feeding tubes.

We mentioned that we might consider placing one in Rex's case and have a think about what you would place. Most commonly used are nasoesophageal and esophagostomy tubes. If you're listening from another country, you might be more familiar with placing NG tubes in nasogastric tubes.

We can talk about that in a moment. Gastrostomy tubes are used much less frequently. It's even in in referral tend to be reserved for patients with oesophageal disease.

So are you placing feeding tubes in your clinic? If you're not and you are hospitalising sick cats regularly, for example, and seeing a high cat case load, I would encourage you to consider it. So nasal esophageal feeding tubes and the same applies for the nasogastric feeding tubes.

Well, they're really suitable for short term nutrition only. We're talking about around 5 days, and there are a few contraindications such as nasal disease, although I will say that they are still useful for cat flu cats depending on the, you know, severity of their, their kind of nasal irritation and congestion. We can place them conscious, although I note that in countries that place a lot of NG tubes, they will often place them sedated.

If we are going to place them conscious, then we want to have all our cat friendly, our cat friendly clinics, protocols in place, and we may want to consider placing it, for example, after they've had a dose of buttrophenol, or if they're on opioids, then time the placement after they've had those opioids. Gabapentin can also be very useful to facilitate something like this. What is good about them is we can feed them straight away.

What's bad about them is that some cats don't tolerate them brilliantly. They don't like having things on their faces. We can't really give anything except liquid meds down them because we're going to obstruct the tube, and we can only really give liquid diets, so again, we're going to obstruct the tube.

OK. And you've got to see a video playing here that shows you how to place feeding tubes, and this is part of the videos that I mentioned to you that we created as part of our in absent cat guidelines. If you want to see the rest of that video, I've got a QR code for you here.

OK, you can also find it with the guidelines. What about esophagostomy tubes? Well, we can place those under a short GA and that is their disadvantage.

We do require a GA. However, when you're familiar with the technique, that actually doesn't take terribly long to do. And there are a lot of situations that we may be wanting to anaesthetize sick patients, for example, to have surgery, in Rex's case, perhaps to do some diagnostic tests, for example, imaging.

So we're gonna think about every opportunity that we have to place them. You can use them immediately, you can use a tube that has a larger bore, so therefore we can give a different range of diets and we can also provide medication. Cats can be discharged with these in situ, and owners can manage them at home.

And again, we've got the supportive material for you to do that. You can leave them for months. Don't put Elizabethan collars on.

You can use, there are a range of companies that produce fabric collars now that work very, very nicely. And it is still likely that they are underused, and there are patients that would benefit from having these placed. And you can remove them immediately if a cat eats very, very well after surgery.

But what's frustrating is if you don't place one and then they're inapetent after surgery, it becomes difficult to medicate them. You can't send them home because they can't be medicated. You can see, etc.

Etc. Complications of O tubes you may encounter now and again, and the most common of those are gonna be tube dislodgement and stomocyte infection, basically. And one of these studies that I've put on the screen of quite large numbers of cats shows a very low complication rate, but that stoiccyte infections might be more likely on cats on steroids or chemo, and a lot of, obviously sick patients might be treated with corticosteroids.

So it is something to to think about. Asepsis is obviously very important, changing your gloves and instruments if you've handled around the cat's mouth to turn the tube round. Haemorrhage, thankfully, unusual.

We can see as the cat on this slide, Horner's syndrome, it's unusual and it's very rarely reported actually, but it's something, this is one of my photos because we have, I have seen that. It reverses as soon as you remove the tube or it may actually reverse anyway, cause it's just a neuropraxis from, irritating that vagus sympathetic region of the neck. And thankfully, severe and abscessated cases are very rare, as in this photo, I don't think touching some wood here that I've seen one that bad.

But the other photos of mine, we've certainly seen that type of of irritation, a bit of pus around the the feeding tube. So just to also note how we deal with those is, is certainly increasing the cleaning of them and we can use some antibiotic and antimicrobial impregnated discs and things, but they're quite expensive. You can also put some I just put some.

Cheap and cheerful iodine creams that are widely available on a swab and put that on the site, but often increasing the cleaning of the area, considering asep system placement very carefully, very, very careful suturing, and you might want to consider suturing and anchoring the tube away from the stoma site. So there are quite a few bits and pieces that you can do to prevent and minimise this. So when are we going to place a tube?

Well, we've sort of touched on this really and kind of mentioned it. You might place them in cats with jaw fractures and traumas. That's quite a common reason people are confident to place them.

But also consider, as we said, cats that are consuming less than RER for 3 days or more. That won't be every case and it will obviously depend on the underlying disease, and it will depend on the client as well. But there are other situations that you might not have thought of using feeding tubes, things like chemo patients.

So if they're having, regular treatment that knocks their appetite for a couple of days and they're having medications, this can really buy us a bit of, a bit of time to not have to worry about that and get our treatment underway. Ex-lapse, liver biopsies, these type of situations, and actually mycobacteriosis treatment, for example, quite commonly, those cats will be on 3 antibiotics for 3 to 6 months. I couldn't do that with my cat.

So having a feeding tube means that owners can stress free medicate their patients. And they can go home. We said that cat that we can't medicate and isn't eating ends up staying in days and days and days.

They're more stressed, they're more fed up. You can see which way it's going, or they can go home with a tube and have hydration and nutrition in their own environment. And sending cats home is is got to be, you know, a better, much better thing, even no matter how cat friendly you are.

And what diet are you gonna feed? Well, you're likely to be limited really. There are some kind of renal diets available, but the majority of patients is gonna be suitable to give them a recovery diet.

There's one made by Deccra here and obviously there are ones made by Royal Cannon that you may be familiar with. With an O tube of a wide enough bore, you can liquidise most diets, such as AD, for example, to put down those tubes. But these type of recovery diets are designed for this purpose.

There are a few situations where cats can't tolerate the nutrition that are in recovery diets. Hepatic encephalopathy, I can think of a very small handful of patients where we've had to restrict, protein, for example, and none that we had to restrict fat. So even your pancreatitis, acute pancreatitis patients can be fed a recovery food.

How much to feed? Well, it really depends on the case. So if you think about cats had a jaw fracture and therefore it's only had 12 hours of not eating, then that patient could probably be fed their full RER relatively quickly and in few meals because they haven't had a, a sort of shrinking of their, their stomach size because they haven't been eating.

If you have a patient that has had poor nutrition for a couple of weeks, then they are at risk of refeeding syndrome. And so we want to go slowly and the general advice is 1/3 of RER day 1, 2/3 day 2, etc. I want you to be confident to reduce that if you've got really sick patients with ileus or have been in absent for a long time.

We might start with a 5th, AER, and almost trickling a little bit of food in to see how that's tolerated. I want you to be regularly weighing patients, reassessing their hydration, and you may need to make some adjustment for body condition and growth at a later stage. So as we discussed, we're not going to do that in a very acute period.

But kittens, for example, you know, they do have higher, higher calorie requirements. And then think of it as something fluid that you're going to, you're going to adjust over time depending on response. Overfeeding, and as we mentioned, the negative effects of overfeeding, you can see some on the screen, and re-feeding syndrome is not common, but it certainly can happen and I've seen it, seen it happen.

It's a very difficult thing to manage, and very expensive to manage for the client. A few tips for cat friendly tube feeding. Well, as we always say, quiet, gentle handling, allowing cats to relax and adopt a position they want to sit in rather than restraining them and making it all a battle and a difficult situation.

Owners may need to put them in a carrier just to keep them still, you know, but that can be a a comfortable carrier or a bed, something like that, something top opening, you know, where they can, they can sit in it. Some cats can be fed, if they have some appetite and we're topping them up or we're medicating them, they can be given some treats just to try and make it more positive. Don't, if, if we're all in a rush and we're all busy, but if we feed too quickly, we can cause nausea and therefore negative associations with both handling and particularly with with being fed by the tube.

And obviously things like warming to to body temperature. Monitor that cat for things like exaggerated swallowing and lip licking, etc. And making sure that they're not feeling really, really unwell, and as I say, emotional discomfort, what do I mean?

That make them very, very anxious with with hefty restraint. And what about syringe feeding? Just to finish, I want to, to sort of ask you about this.

Now, whenever I give talks about inhabitants, we, we do sometimes encounter vets and nurses who, who deal with often colleagues in the clinic who are adamant that patients should be syringe fed. But there are good good reasons not to syringe feed. Well, for a start, you have to syringe feed loads of food to meet their energy requirements.

It involves you doing it several times a day, making everybody miserable. The stress of, of doing that, has got to be considered. But actually on a more serious note, we certainly hear about the odd case of aspiration pneumonia, which even can be er fatal in patients, you know, they get distressed and and inhale the food.

And I don't think it's hard to see how it could cause nausea and food aversion. If you and I felt a bit poorly and someone liquidised a roast dinner and then tried to hold you down in hospital in a stressful environment, and the nurse, you know, one nurse held your head and the other one syringed food into the side of your mouth. I know I'm being horribly anthropomorphic, but I think it's reasonable in this situation.

And actually it can put cats off eating full stop. So you do that, they are not going to eat. OK, and the same applies for kind of putting food on feet and on the side of the mouth and You know, we're not going to meet any calorie requirements with this type of thing, and it's very unlikely to suddenly trigger them to eat enough.

So there are better ways really. And actually there's a study here that I've referenced that shows that force feeding, is very unusual for it to meet energy requirements. OK, so you can see from that that that voluntary intake or or using enteral feeding, which is tube feeding, is more likely to meet their actual energy requirements.

So what happened to our patients? Let's go back to them. Well, here's Rex, and it won't surprise you considering how yellow he is for me to tell you that his bilirubin on presentation was about 150, so very, very high.

But by the time after 5 days, he'd been managed for his diagnosis, which was pancreatitis and, and, cholangitis, he actually improved really, really well with his antibiotic and other therapies. To the point where on discharge his ALT was normal. We'd placed a feeding tube, an O tube at, as I mentioned, the time that we did some diagnostic tests, and that allowed us to medicate him and to feed him very, very promptly, and I, I'm sure assisted this relatively rapid recovery from, quite a severe episode.

I didn't take it out. I sent him home with it because the owners could then give him ongoing antibiotic therapy and other treatments. Obviously, we have had sporting medications, for example, down the tube without any stress, and we only remove it when they're consistently eating.

And sometimes I'll leave it in then for an extra few days depending on their medication requirements. So that cat that you take in for the liver biopsy or the foreign body removal, if you place a feeding tube, you can remove it when they're eating straight away. But often owners will ask you to leave it in for a few days so that they can medicate them much easier.

And Princess, she had her mirtazapine treatment and it did seem just to pick up her appetite, and that helped with hydration. It also, I think, helped to facilitate us medicating her with potassium supplementation and furozamide and obviously that, that challenging balance between chronic kidney disease and congestive heart failure. However, she had 6 months, which I don't think is is bad considering the severity of her renal disease and her development of, of congestive failure.

So I don't consider that a bad outcome, and you've got to wonder if you would have gone a different direction had her appetite and hydration not been improved. So just in summary, in appettent cats, there's a lot of reasons for them to be inappotent as well as the primary disease, and this is particularly something we see in hospitalised patients when we add in drugs, stress, etc. Nutritional assessment, I hope you can see the benefit of doing that, and I hope it would give you, you know, the confidence to to intervene and identify cats that require intervention rather than leaving it for another day.

Appetite stimulants can be useful, but obviously use them at the right time in the right situation, and that there may be a few situations that we haven't thought of using them that cats could benefit from, but equally, other situations where we don't want to use them and causes a delay in intervening and, for example, placing feeding tubes. And of course, cat friendly clinic is something that's very important to me. So I want you to remember the role of stress in your hospitalised cats and manage that.

Thank you very much for listening, and a not so subtle plug to have a look at membership of ISFM. If you're interested in cats and you're seeing lots of cats by joining ISFM, which is very cheap, really. We get lots and lots of webinars, lots of sorts of material, and part of our, our cat community.

And thanks again to Dera for asking me to speak to you this evening.