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Notes:
- Daily Dosing. Fasting is
unnecessary UNLESS the cat's calcium is high normal
or higher. Dr. Nagode's preference is always for
animals with calcium issues to receive every 3.5 day
dosing but if that's not possible and daily dosing
is necessary, he recommends that cats with high
normal or elevated calcium be fasted. He suggests a
pre-fast running 2-4 hours and a post-fast from 30
minutes-1 hour – the higher the calcium values, the
longer the pre and post fasts. (see #3 below for
more details on suggested fasts).
- For animals on every 3.5 day
dosing with calcium below top-end of normal.
Fasting is not required if the animal's serum
calcium is in the lower-half of the normal range.
For cats with serum calcium in the upper half of the
normal range but lower than the top-end of said
range, Dr. Nagode suggests a minimal fast --- 1 hour
before calcitriol administration and 15-30 minutes
after. "Although doses each 3.5 days are higher than
daily doses, I would rather use the terminology that
"fasting is advisable" rather than mandatory. This
would be particularly true for the somewhat unusual
case in which the calcium levels were running on the
low side and owner wished (presumably for economic
reasons) to dose each 3.5 days--then fasting would
be of little value. As a precaution, for those with
calcium [values] running from mid-normal range to
upper limit of normal, however, I would say that
it's advisable--but would not wish to go to
mandatory" with final judgments made in consultation
with the local veterinarian who is on the scene and
can make judgments based on all the information at
hand."
- For cats on every 3.5 day dosing
with calcium values at the top end of the normal
range or higher, Dr. Nagode recommends fasting. "My
definition of a fast is conditional upon how marked
the calcium problem is. For truly worrisome
elevations like over 13 mg/dl total calcium both
going to intermittent dosing and a 3-4 hour before,
1 hour after would be indicated. Milder elevations
could go with say 2 hour, 30 minute approach with
extent of fast modifiable depending upon what the
results of subsequent blood calcium checks were. All
of these strategies are impacted by outcomes
(resulting blood calcium levels) and modifiable also
in accord with how the outcomes fall out. Setting
hard and fast protocols are therefore --although
seemingly desirable--better avoided with a "feeling
the way" to best outcome almost always the better
approach."
- Last, even for cats being dosed
every 3.5 days and in the lower half of the normal
range, Dr. Nagode suggests in his protocol that " …
when doses > 5 ng/kg are needed
[Editor: every 3.5 days doses are all
> 5 ng/kg] … best given at bedtime on an empty
stomach to prevent hypercalcemia." But Dr. Nagode
expands on this in the following, noting that it's
desirable rather than necessary and may be precluded
by the circumstances of an instant case. "… it
[every 3.5 day dosing] has come into use probably
more than for any other reasons for financial ones
in that it is cheaper and almost certainly (evidence
is not as complete as many would wish) just as
effective as daily dosing and thus in instances in
which hypercalcemia is not feared or existing empty
stomach dosing is not as critical. Is it
recommended? I would say, yes it is likely wise. Is
it MANDATORY? -- I would say no --in many instances
such as in particular those described by a [Yahoo
Calcitriol] group member ... who had great problems
due to many circumstances in keeping her cat
adequately fed … [due to] many such factors,
therefore, I think it is better to use terms like
"suggested." etc., rather than required," although
the latter may be more satisfying for the
purposes of creating guidelines, they for one thing
cut the local veterinarian's judgment (which can be
very valuable considering those factors which impact
the "whole picture") out of the picture leading
owners to views that they "must" do things in a
rigid defined way when this may or may not be the
case depending upon circumstances.”
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