VetInfo Digest February 2003
Who is Geriatric?
Feeding Older Pets
Aging Disorders to Keep in Mind:
Arthritis
Heart Disease
Hyperadrenocortism
Diabetes
Hypothyroidism
Cancer
Airway Disorders
Hyperthyroidism
Hypertension
Kidney Failure
Liver Disease
This Month's Note:
I have gotten a lot of questions this month about health problems in older dogs and cats. There is no recognized specialty in geriatric veterinary medicine at the present time. For this reason, it is sometimes difficult to find a veterinarian who has a strong interest in geriatric medicine. In general, this is a field in which veterinarians tend to be under trained and sometimes just less interested than they really should be. To some extent, I think that this results from the availability of euthanasia as an option, combined with sensitivity about monetary issues in both veterinarians and their clients. The medical issues facing older patients are really just standard medical problems. They can usually be treated in the same exact manner as they would be handled in a younger patient. There are times, though, when it is necessary to adjust dosages or to make modifications in treatment plans to accomodate pre-existing problems in older patients. In addition, it is important to remember to keep overall health in mind when anticipating the outcome of a surgical or medical procedure. Fixing a broken leg in a young patient might really make them "almost good as new" while doing the same procedure in an older dog may involve protecting against increased arthritis pain in other limbs that have to do more work while the injured leg heals -- and these pains will continue despite a successful fracture repair. Thinking about the whole patient is more important in geriatric medicine and really is the key to successfully helping older dogs and cats live longer healthier lives.
Who is Geriatric?
The first problem when discussing geriatric medicine is deciding who is geriatric and who isn't. Most of the current guidelines look more like marketing efforts to promote older age pet foods or medicines intended for older patients than thoughtful considerations of the aging process, to me. I try to think about each patient individually and to assess how age is affecting them. For this reason, most of the patients I think of as geriatric are older than commonly promoted guidelines for official "old age", such as eight to ten years for small dogs, six to eight for large dogs and ten to twelve years of age for cats. Usually, I have a hard time thinking of a patient as geriatric until their health starts to interfere with their normal activities or until they require two or three medications on a chronic basis to control persistent health problems. However the term "geriatric" is ultimately defined, the problems associated with geriatric medicine are often chronic and incurable but can usually be successfully managed for long periods of time.
Feeding Older Pets
Weight control seems to be a real challenge for many pet owners. Excess weight is more damaging than most pet owners realize. Arthritic pain appears to respond as well to weight loss as it does to anti-inflammatory medications. Purina (tm) has recently published data showing that dogs who are near their ideal weight live 25% longer than overweight pets. Many illnesses may be worse, or have earlier onsets, in overweight pets. This is especially true for pancreatitis, diabetes, chronic respiratory disease and heart disease. The true extent of the effect that excess weight has on aging is not known but is probably greater than most people realize. These are some things to think about when considering weight control:
1) It is possible to simply withhold food from dogs until they reach their ideal weight and then start feeding them again, without much risk of causing additional health problems. While no one really advocates doing this, knowing that dogs do not develop problems when food is withheld is reassuring.
2) Cats may develop progressive liver disease due to fat accumulation (hepatic lipidosis) when they stop eating for any reason and in some cases when their calorie intake is simply reduced. This problem is actually more likely to occur when a cat is overweight to begin with. For this reason, it is necessary to be more cautious when attempting to control excess weight in cats.
3) We find that many pet owners can manage to control their pet's weight through the simple step of accurately measuring the amount of food that they give and adjusting for dietary recommendations, using real measuring cups instead of "Big Gulp" cups or feed scoops.
4) There is a recent trend among cat veterinarians to attempt weight control by feeding high protein, low carbohydrate diets. This seems to have been initiated by recognition that many cats fed Purina's DM (tm) diet made for dietary management of diabetes, containing 51% protein, often resulted in weight loss. Some vets feel that feeding kitten foods that are at least 40% protein works nearly as well. At this time it is too early to tell if this will work out to be the best approach to weight control for all cats but it does seem to help in many cases.
5) Exercise helps in weight control. While it is easier to induce dogs to exercise, it is often possible to get cats to play with lure toys, laser beam pointers or by walking them on a leash. Moderate exercise is not usually harmful even when arthritis, respiratory or heart conditions are present but be careful to ask your vet for exercise advice if your pet does have one of these pre-existing conditions or you have any other reason to suspect that exercise might cause a health problem.
6) Most people who enjoy giving their pets treats, or sharing foods with them, will continue to do this even during attempts to help a pet lose weight. These interactions are important to both the pet and the pet owner, making it difficult to give up treats. It is often much better to figure out the calories that treats represent and then to subtract the amount of the regular pet food that the calories represent. If treats represent more than 10 to 15% of the calorie intake, it is important to make sure they are either well balanced treats or that the rest of the diet is adjusted to compensate for the protein, mineral and vitamin content of the treat.
7) Many dogs will readily eat green beans, which do not contain many calories, making them a good substitute for other treats. Other vegetables will also work for many dogs. Cats will even eat these types of treats, sometimes!
Pets with specific disease problems may benefit from specialized diets. There are special diets for kidney failure, heart failure, diabetes, liver disease, and even senility in older pets. It is not possible to cover these diets in this issue of the newsletter but we do intend to cover specialized diets in depth in a future issue.
There is another aspect to weight control that is very important in geriatric pets. For pets with serious illnesses and in many chronic illnesses that affect older pets it is hard to maintain weight. In older pets, weight loss may be the first sign of serious illness, especially diabetes, hyperthyroidism, chronic renal failure and cancer. Accurate measurement of weight on a periodic basis can give an early warning that one of these disorders is present. When weight loss is noted for any reason in an older pet it is a good idea to look for an underlying cause, using screening blood panels and any specific laboratory testing that seems indicated based on physical examination findings.
When pets do not take in adequate calories it can be very beneficial to use assisted feeding quickly. For temporary feeding, a nasogastric feeding tube is fairly easy to place and doesn't require surgery. If a longer assisted feeding period seems likely to be necessary it is better to place a more permanent feeding tube directly into the esophagus or stomach. Many veterinarians are very reluctant to use surgically placed feeding tubes to allow owners or the veterinary staff to control caloric intake by feeding the pet through the tube. This is a major step, involving slight anesthetic risks, some chance for infection and more nursing care. We were very reluctant to place gastric (directly into the stomach through the side of the abdomen) feeding tubes in pets, feeling that the risks outweighed the difficulty in force feeding pets with a syringe in many cases. Esophageal feeding tubes, which have been used only in the last few years, have greatly reduced these risks and these tubes seem easier to manage, as well. We have been much quicker to offer to implant feeding tubes using this technique and more aggressive use of this method to help pets maintain calorie intake seems to really help in many chronic illnesses. It is vitally important when cats are not eating at all to supplement feeding to prevent hepatic lipidosis. In both dogs and cats, assisted feeding can be a great benefit in helping to maintain weight when chemotherapy is being used to fight cancer. For some reason placing a feeding tube seems too radical for many veterinary clients. This is a shame, especially when the supplemental feeding seems likely to be a relatively short term need. It is a critical error to delay placing a feeding tube in a cat that is not eating. It is much better to place the tube and find out it wasn't necessary than to avoid placing the tube and miss the opportunity to treat hepatic lipidosis until it is too late.
Disorders to Keep in Mind with Aging in Dogs and Cats
Age does lead to some chronic problems in dogs and cats. Some of these are important to think about as pets get older and may justify more extensive yearly physical examinations. The addition of routine blood work, chest or abdominal X-rays, increased emphasis on dental health and other testing procedures are all reasonable procedures for older pets to have on a regular basis. Dogs and cats differ somewhat in the diseases most likely to cause problems with advancing age.
Dental disease is more common in older dogs and cats. Older pets really should have both a yearly physical examination and a yearly dental examination that includes scaling and polishing the teeth, if necessary. This is one of the most neglected areas of pet care, especially since the benefits of correcting dental disease can be almost amazing in some patients. Small breed dogs, especially poodles, Yorkshire terriers and Cavalier King Charles Spaniels seem to benefit the most from regular dental care. Cats who quit grooming with age often do so due to dental disease or arthritis and correcting these problems can be very beneficial to the cat's overall health.
I know that we covered dental disease in a recent issue of the VetInfo Digest and I will not belabor this point here, but please remember that the risk of ignoring dental problems in pets is far greater, on the average, than the risk that anesthesia presents. Many more pets are disabled, suffer needlessly and die from lack of dental care than have adverse consequences such as blindness or death following anesthesia. It is not possible to make anesthesia completely safe but controlling dental pain is worth taking some risk.
The most common geriatric problems in dogs include the following disorders; chronic heart failure, hyperadrenocorticism, diabetes, hypothyroidism, cancer, arthritis, dental disease, arthritis and upper airway disorders.
The most common geriatric problems in cats include cardiomyopathy, diabetes, hyperthyroidism, hypertension, kidney failure, chronic liver disease, cancer and arthritis.
Arthritis
Arthritis is very common in both dogs and cats and it gets worse with age. Most of my clients do not take arthritis pain seriously enough, possibly because they themselves are too young to appreciate just how debilitating it can be. When a dog is having difficulty getting up in the morning, many of my clients assume it is muscular weakness. It is far more likely to be due to arthritis. When cats stop running up the stairs and start walking slowly up them, they are very likely to have arthritis. Oddly, some cats with really severe arthritis, plainly visible on X-rays, will still insist on jumping up or down from high places. Some dogs with severe arthritis can hardly move until they see a squirrel, but then forget all about their joint pain. These types of behaviors do not indicate that the pain is not worth worrying about. They are just an indication that pets will sometimes put pain aside when they have enough of an adrenaline rush or when they really feel the desire to.
The best way to decide if pain control is necessary when signs of arthritis occur is to use it to see if there is an improvement. In general, I like to use the most potent pain reliever and/or anti-inflammatory medication that I can for testing. If there is a huge improvement with a medication that generally works well, I am comfortable scaling back to less potent medications to see if they will also provide good pain relief.
In dogs, this usually means using either carprofen (Rimadyl Rx) or deracoxib (Deramaxx Rx). Rimadyl will sometimes cause severe liver disease in dogs. This is an uncommon effect but it is extremely important to be aware of it. It is best to run blood tests to identify any pre-existing liver disease before using Rimadyl for more than a few days and to recheck the lab work after two to four weeks. This is a situation in which the risk of use has to be balanced against the need for the medication. I can say from personal experience that relief from arthritis pain justifies taking some risks and so I am comfortable dispensing Rimadyl.
In cats the situation is a little more difficult, since there are fewer choices in pain relief medications. We sometimes use a short course of a corticosteroid, such as prednisone. In other cases we opt for pain relief using narcotic medications or carefully controlled aspirin therapy. Meloxicam (Metacam Rx) is approved for use in cats in Canada and some other countries. It is available in a human formulation in the U.S. and is sometimes used off-label for cats. We have not tried this medication at this time but the reports on its use from other countries seem to indicate that it is fairly effective. We have used piroxicam (Feldene Rx), another human medication, in a few arthritic cats. It seems to be beneficial but it is necessary to be very careful to watch for gastrointestinal irritation from this medication and to withdraw it if any signs occur.
When arthritis is recognized early, the use of glucosamine and/or chondroitin (500mg glucosamine/400mg chondroitin per 25 lbs of body weight per day) may be helpful. Supplementation of omega n3 fatty acids (essential fatty acids) or Vitamin E can be beneficial to some patients with arthritis, as well.
Back pain is also common in dogs as they age. It is less common in cats but does sometimes bother cats, as well. Chronic disc disease can occur in dogs and may mimic arthritis or even be mistaken for degenerative myelopathy, which is not treatable. Back pain will often respond to medication. In some cases surgery is a good option, as well. Due to the differences in therapy, it is important to differentiate between back pain and arthritis. Making an effort to get a diagnosis is worthwhile to ensure that the correct treatment is being pursued. When degenerative myelopathy is diagnosed it may be worthwhile to consider the possibility of getting a magnetic resonance (MRI) scan, as recent studies seem to indicate that some cases diagnosed as degenerative myelopathy actually have intervertebral disc disease that does not show up well with myelography, which has been the standard diagnostic test for disc diseasee in dogs and cats.
Chronic heart failure (CHF)
Chronic heart failure is common as dogs age. In most cases in dogs this occurs due to failure of the mitral valve in the heart, although other valves may be involved and other forms of heart failure do occur. When mitral valve failure is present there is usually, but not always, an audible murmur that is loudest on the left side of the chest. The presence of a murmur is not a definite indication that heart failure is present. At the present time there is no strong evidence to suggest that treating dogs with murmurs but no symptoms of heart failure does any good. Signs that treatment for heart disease is necessary include tiring readily, coughing frequently and fainting. X-rays help in determining if heart failure is present because they show fluid accumulation in the lungs very well. There are good medications for heart failure. The most important medications continue to be diuretics to help control fluid accumulation in the lungs and ease the work load of the heart. Furosemide (Lasix Rx, Salix Rx) is the best of these. Angiotensin-converting enzyme inhibitors ( ACE inhibitors) such as enalapril (Enacard Rx, Vasotec Rx) are helpful, as well. There is some evidence that spironolactone, another diuretic, can be helpful when used in combination with other medications but it is generally not a good choice as the sole diuretic for treating heart disease in dogs.
Heart disease in cats
Cats are more likely to develop cardiomyopathy, or weakness of the heart muscles, as they age than the valve failure that occurs in dogs. Cardiomyopathy can be a secondary problem related to hyperthyroidism or hypertension or it can occur on its own. An increase in respiratory rate, especially excessive respiratory effort after mild to moderate exercise is often the first hint that cardiomyopathy may be present. Cats are very good at hiding illness and consequently cardiomyopathy may not be detected until a real crisis occurs. Cats who are having extreme respiratory difficulty may have to be allowed to find a hiding place and allowed to calm down prior to making any diagnostic or treatment efforts. In some cases, supplemental oxygen is necessary but has to be administered in a non-threatening way. Waiting while their cat is in distress can be hard on pet owners but holding a cat to withdraw fluid from the chest, take X-rays or attempt other therapy is more likely to be fatal than waiting to proceed when the cat has settled down some. Cardiomyopathy will often respond at least partially to medical therapy but is less responsive to therapy than the chronic valve failures that occur in dogs. The only definitive way to diagnose cardiomyopathy is cardiac ultrasound examination.
Hyperadrenocorticism (Cushing's disease)
This is really a general name for a group of conditions that lead to excessive cortisone production by the adrenal glands. Most dogs with Cushing's disease are over nine years old at the time of diagnosis (>75%). It is unusual to see this disease prior to six years of age but it does sometimes occur in younger dogs.
Testing for Cushing's disease is not usually done routinely. Testing is generally prompted by the clinical signs, although it is also done by many veterinarians when the serum alkaline phosphatase (SAP) level in a routine blood chemistry test is elevated, especially when other liver associated enzymes are within normal ranges. It is reasonable to test several times when clinical signs are present but test results do not support a diagnosis initially. It is debatable whether there is any advantage to treating for Cushing's disease prior to the time that clinical disease makes it necessary to do so. It is important to confirm the diagnosis of hyperadrenocorticism and also to do further testing to establish whether the disease is caused by problems in the pituitary gland or in the adrenal gland, as treatment for the two causes is different. Not testing for this difference is a common omission in veterinary medicine.
Diabetes
Increased drinking and urinating are the most commonly recognized signs of diabetes. Many pets with this disease will have changes in their hair coat, such as increased scaling or oiliness, as well. Increased susceptibility to other infections is also sometimes noted.
It is reasonable to screen for diabetes using urinalysis or blood glucose testing in pets over 6 years of age. A general blood chemistry panel will include a test for glucose levels in the blood. It is not unusual to find diabetes on routine testing when it has not caused enough clinical signs to make the pet owner suspicious of a problem.
Hypothyroidism
Hypothyroidism occurs when there is insufficient production of thyroid hormone by the body. In dogs this occurs as an immune mediated disease about half the time and for unexplained reasons in the rest of the cases. Hypothyroidism can have many signs and has been linked with many other conditions. The most consistent signs are dulling of the haircoat, poor hair growth, and hair loss. Increased drinking and urinating sometimes occurs with this condition. Some dogs "heat seek" or look for the warmest spots to lie down in. Weight gain occurs in some dogs. Increased susceptibility to skin infections and ear infections has been noted. Hypothyroidism has been linked to laryngeal paralysis and megaesophagus but these links have not been convincingly proven at this time.
Most veterinary endocrinologists discourage routine testing for hypothyroidism because the disease is somewhat difficult to diagnose based on total thyroxine (TT4) levels, which are the most commonly run screening test. It is probably better to test for hypothyroidism only when there is reason to suspect that it might be present. When testing for hypothyroidism the best test currently available is a free thyroxine level (fT4) run by equilibrium dialysis (fT4ed). This test is not available as an in-house test but is run by several commercial labs or college labs, including the Michigan State University endocrinology lab, which is one of the best endocrinology labs in the country.
Cancer (Neoplasia)
The term cancer is used differently in veterinary medicine from its normal use in human medicine. Veterinarians consider cancer to be the abnormal production of cells leading to a tumor. From that point, veterinarians further divide cancers into benign or malignant. Benign cancers usually do not spread far, although they may be locally invasive. Malignant tumors spread aggressively in local tissue or spread to other areas of the body. In people there seems to be a tendency to talk about tumors and cancer, using the word tumor to substitute for the veterinary "benign cancer" and the word cancer to exclusively pertain to the veterinary "malignant cancer". This can be very confusing to pet owners and probably leads to some undue anxiety when veterinarians don't catch on to the confusion.
In veterinary medicine cancer is sometimes billed as the most curable of chronic illnesses, since it is often possible to remove benign tumors and eliminate them and even sometimes possible to cure malignant cancers through surgery or combinations of surgery and chemotherapy or radiation therapy. It is important to remember that not all cancers are alike. Some cancers are very aggressive and very unresponsive to therapy, while others are much more likely to be a problem. Cancer has to be considered in older dogs and cats when there are signs of chronic illness such as weight loss or anemia but no obvious clinical signs of a specific disorder. Surprisingly, most pets with cancer have normal blood chemistry values and often have normal red and white blood cell counts, although anemia is common as cancer progresses. Routine physical examinations often offer the best hope for finding cancer. It is particularly important as pets age to schedule at least a yearly physical examination and twice yearly examinations make sense for older pets, especially after chronic problems begin to surface. A simple test for determining if lumps are cancer is to suck a small sample of the tumor into a needle and then to smear this on a slide and examine it microscopically. It is reasonable to do this simple test for any skin lump or accessible lump in other locations.
Airway Disorders
Upper airway diseases are common in older dogs and not uncommon in older cats. The most common upper airway diseases are collapsing trachea syndrome (dogs), laryngeal paralysis (dogs and cats), chronic bronchitis (dogs and cats), and pharyngeal or nasal passage cancer (dogs and cats).Collapsing trachea syndrome is most common in toy to small breed dogs but can occur in any size dog. The trachea can be affected anywhere along its length. Dogs with this condition frequently have a harsh cough. It can occur in young dogs but gets more common as dogs age. If the collapse is in the portion of the trachea in the neck it can be palpated in many dogs. If it is in the chest or entry to the chest it is usually necessary to find it with X-rays or endoscopic examination of the trachea. This condition is common enough that it is sometimes diagnosed when it isn't present, so confirmation is worth pursuing.
Laryngeal paralysis is most common in large breed dogs but seems to also affect enough cats to warrant thinking of it when voice changes or harsh breathing sounds are noted. In older dogs this condition can be devastating, as it frequently leads to heat stroke during warmer months. It is critically important to keep dogs with laryngeal paralysis cool. Even short periods of exposure to heat can lead to problems. There are surgeries to correct this problem but it is probably best to avoid surgery if the symptoms (harsh breathing, respiratory distress) can be controlled by weight loss, keeping the pet cool and limiting activity. Most veterinarians can identify the possibility that laryngeal paralysis might be present based on listening to breathing sounds during a physical exam. It is confirmed by examining the larynx under anesthesia.
Cats sometimes get an inflammatory laryngeal disorder that may require lifelong therapy with low doses of cortisone to control. This condition is best diagnosed by biopsy of the inflamed area, as it closely resembles cancer in appearance. All cats suspected of having laryngeal cancer should have biopsies prior to the consideration of euthanasia due to the possibility of this condition, which is responsive to therapy.
The most common cause of bleeding from one nostril in older dogs and cats is cancer. Nasal tumors are fairly common and can be very hard to accurately diagnose. Magnetic resonance imaging, computerized tomography and direct visualization of the nasal passages by endoscopy offer the best chance for a confirmed diagnosis.
Hyperthyroidism
Cats tend to have too much thyroid hormone, rather than too little. The incidence of this problem in cats over 9 years of age may justify routine testing for this condition on a yearly basis. An alternative approach, that is probably just as good, is to test whenever weight loss occurs in the absence of a concerted effort on the part of the cat owner to cause weight loss through dieting. Increased appetite combined with weight loss is typical of hyperthyroidism and many cats are also restless and may vocalize more than they did in the past.
The total T4 test is considered to be reliable for this condition if it is elevated. So routine screening makes more sense for hyperthyroidism than for hypothyroidism in dogs. An increased heart rate (over 220 beats per minute), weight loss with a normal or increased appetite, an unexplained "scruffy" appearance or unexplained hypertension all are sufficient reason to look for hyperthyroidism. It is best to do routine screening or to maintain a high degree of suspicion for this condition and to test accordingly.
Hypertension
High blood pressure as a primary disease is more common in cats than it is in dogs. The first sign that many pet owners notice for high blood pressure is sudden blindness when it leads to retinal detachment. If treated promptly most cats will regain their sight but this is hardly the ideal way to diagnose the condition. It is reasonable for your vet to test for high blood pressure during routine examinations. The testing requires more expensive equipment and/or a greater technical ability than testing humans, so most vets do charge for this testing. Cats are sometimes really put off by the testing and so it is recommended that at least three measurements (or perhaps two if they are very consistent) be taken. There are good medications to control blood pressure in cats. Amlodipine (Norvasc Rx) is currently the favorite but many vets are also happy with enalapril and similar ACE inhibitors.
Kidney failure
Cats are very prone to chronic renal failure (CRF). This condition should probably be referred to as chronic renal insufficiency, because the kidneys are able to function at a reduced level and this is often sufficient to keep the cat comfortable for long periods of time.
Chronic renal failure should be suspected when weight loss occurs in older cats. Clinical signs include increased drinking and urinating, decreased appetite and increased blood pressure. CRF is probably the leading cause of hypertension in cats, although it is a secondary disease in this case. It is reasonable to do routine blood chemistry and/or urinalysis testing as a part of routine physical examinations in older cats due to the high prevalence of this disorder in older cats. Increases in blood urea nitrogen (BUN) and creatinine, decreases in potassium levels or albumin levels, anemia and increases in phosphorous can all occur in the blood work. The earliest sign in some cats is the drop in potassium and this sign warrants closer observation for the development of CRF. Urinalysis usually shows a decrease in urine concentration (specific gravity). If a cat can not concentrate urine to a specific gravity above 1.030 on several tests it is highly likely that CRF is present.
Kidney insufficiency is very responsive to therapy in most cats and it is important to start therapy early and to be aggressive about therapy when crises occur. Many cats can live through several crisis periods when dealing with CRF, if treatment at the time is aggressive.
Chronic liver disease
Chronic liver disease, especially a condition in which liver disease, pancreatitis and inflammatory bowel disease occur concurrently called "triad syndrome" is very common in older cats. This condition is usually noticed by cat owners due to weight loss, vomiting and/or increases in drinking and urinating. Some cats just seem to be depressed or chronically lethargic. Chronic liver diseases are fairly common in dogs, as well.
Liver disease can often be detected before it becomes symptomatic through routine blood tests. Rises in serum alkaline phosphatase (SAP) occur with liver disease as well as a number of other disorders. In dogs, when the SAP rises and no other liver values rise it is best to look for other causes, especially hyperadrenocorticism. There is a liver disorder, benign nodular hypertrophy, that is very common in older dogs. This disorder causes rises in SAP only and is not harmful to dogs. It is important to remember that this condition occurs when considering changes in the SAP value in older dogs. In cats, rises in alanine transferase (ALT) are almost always a true indication of liver disease and should prompt an effort to identify the disease. SAP and ALT detect damage to liver cells. Bile acid response testing is the most accurate test for liver function, which can be normal even when some of the liver is severely damaged.
Anytime a cat stops eating for more than 3 to 5 days for any reason it is best to maintain a high suspicion for hepatic lipidosis, a liver disease that occurs when cats do not eat well. This condition is more prevalent when cats are overweight then stop eating but it can occur even in thin cats. We see hepatic lipidosis in combination with hyperthyroidism in some cats who are eating well, probably because their energy needs are so high that they metabolize fat even though they are eating a lot. Hepatic lipidosis can occur in cats who are eating but not taking in enough calories. In this case it may show up after weeks or months of inadequate caloric intake.
Chronic liver disease in both dogs and cats and triad syndrome in cats all often respond well to treatment so early diagnosis is helpful.
To send subscriber questions for advise on pet health, please use the e-mail address mervet@inna.net, which goes to Dr. Richards directly. For help using the website or technical questions, please send mail to vetinfo@vetinfo.com, which goes to Michal Justis.
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This page was last edited 06/15/04
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