Notes:
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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).
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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."
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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."
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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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