19633

e2014

JFM0010.1177/1098612X13519633Journal of Feline Medicine and SurgeryHiggs et al

Original Article

Medical management and monitoring

of the hyperthyroid cat: a survey of
UK general practitioners

Journal of Feline Medicine and Surgery

2014, Vol. 16(10) 788795
ISFM and AAFP 2014
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1098612X13519633
jfms.com

Paul Higgs1, Jane K Murray1 and Angie Hibbert2

Abstract

Feline hyperthyroidism is commonly diagnosed in general practice. This study assessed the opinions and
experiences of UK general practitioners (GPs) regarding the management of feline hyperthyroidism. This
included an evaluation of preferred treatment modalities and the monitoring of medically treated cats in relation
to thyroxine (T4) level, co-morbid disease and adverse drug reactions. Six hundred and three GPs completed
an online questionnaire comprising 34 questions. Oral medication was the most commonly preferred treatment
option (65.7% of respondents), followed by thyroidectomy (27.5%) and then radioiodine (5.5%). When cost of
treatment was eliminated as a consideration factor, significantly more respondents selected radioiodine (40.5%,
P <0.001). Concerning target total T4 levels during medical management, 48.4% aimed for the lower half of the
reference interval (RI), 32.3% anywhere within RI, 13.1% within the top half of RI and 0.5% above the RI; 3.4%
evaluated efficacy by physical assessment only. In the presence of chronic kidney disease (CKD) respondents
were significantly more likely to target total T4 levels within the upper half of the RI (40.3%) or above it (9.8%) when
compared with targets for routine cases (P <0.001). Assessment for unmasking of CKD after initiating treatment
or for hypertension was not consistently performed. Variability in monitoring strategies may result in CKD and
hypertension remaining undetected, inadequate suppression of T4 levels in cats with concurrent CKD and delayed
recognition of potentially significant haematological abnormalities.
Accepted: 7 December 2013

Introduction
Feline hyperthyroidism was first reported in 1979 and,
since that time, has increased in prevalence to become
one of the most commonly diagnosed endocrinopathies.1
The diagnosis of hyperthyroidism is routinely made in
general practice, with at least 91% of cases being confirmed on the basis of elevated total thyroxine (T4) levels.2 There are currently four treatment modalities
available, including anti-thyroid medications, surgical
thyroidectomy, radioiodine therapy and, more recently,
iodine-restricted dietary therapy.3,4 Choice of treatment
modality is believed to be strongly influenced by the
individual general practitioner (GP) and is likely influenced by their experience, prior education and awareness of current literature, and specialist opinion.
Treatment options for hyperthyroidism can be separated into those that are potentially curative (radioiodine,
surgical thyroidectomy) and those that require life-long
intervention and monitoring (anti-thyroid medication,
iodine-restricted diet). Most cats will receive anti-thyroid
medication at some stage, either for short-term

stabilisation before thyroidectomy or radioiodine, or for

long-term therapy. Currently, there are two licensed
forms of oral anti-thyroid medication available in the UK
(methimazole [Felimazole; Dechra Veterinary Products]
and sustained release carbimazole [Vidalta; MSD Animal
Health]). A transdermal methimazole formulation (unlicensed) became available in August 2012, around the
time of data collection for this study.
Co-morbid disease is common in hyperthyroid cats;
chronic kidney disease (CKD) can be masked owing to
the increase in glomerular filtration rate (GFR) associated with hyperthyroidism and azotaemia may only
1School

of Veterinary Sciences, University of Bristol, Langford,

Bristol, UK
2The Feline Centre, Langford Veterinary Services, Langford,
Bristol, UK
Corresponding author:
Paul Higgs MA, VetMB, CertSAM, MRCVS, School of Veterinary
Sciences, University of Bristol, Langford, Bristol, BS40 5DU, UK
Email: paul.higgs@bristol.ac.uk

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Higgs et al

789

become evident once the cat becomes euthyroid.5

Additionally, while hypertension has been identified in
22% of newly diagnosed hyperthyroid cats before treatment is initiated, 2224% of previously normotensive
cats develop hypertension following treatment for
hyperthyroidism.6,7
Despite the widespread use of anti-thyroid medications there is a lack of consensus regarding the best practice for monitoring the response to treatment,
identification and impact of co-morbid diseases (eg, cardiac disease, renal disease and hypertension), or monitoring for adverse effects of medications. Datasheet
guidelines for the licensed medications (NOAH
Compendium, www.noahcompendium.co.uk) provide
some guidance; however, descriptive guidance for target
serum total T4, the monitoring of blood pressure and comorbid diseases, such as CKD, is lacking.
Although there is research in this area, the literature is
commonly based on referral hospital populations and
may not represent the views and experiences of veterinary GPs, who are responsible for the management of
most hyperthyroid cats. Previous studies have evaluated
the opinions of owners of hyperthyroid cats; however, to
our knowledge, there have been no studies evaluating
the opinions and decision-making process of GPs regarding choice of treatment modality or their approach to the
use of oral anti-thyroid medications.8,9
This study aimed to evaluate how UK GPs approach
management of feline hyperthyroidism. We first hypothesised that GPs would favour oral medication to manage
hyperthyroidism over surgery or radioiodine therapy;
secondly, that monitoring of kidney function and blood
pressure is not routinely practised during therapy; and,
thirdly, that the monitoring for adverse effects of medication lacks a consistent approach.

Materials and methods

Target respondents and questionnaire distribution
The Royal College of Veterinary Surgeons register was
searched for all UK practices that see feline patients;
2431 practices were identified. Contact was directed to
main site practices where branch surgeries existed. An
email address was available for 1960 practices, while 471
had only registered a postal address. An invitation to
complete the questionnaire was distributed via email
where available, the remainder was sent by post. Postal
contact included a covering letter containing information about the questionnaire with a web address, in order
to direct respondents to the online questionnaire.
Most email contact details were generic for public
contact to the practice, for example, enquiries@examplepractice.co.uk, and therefore the invitation also contained a request for this to be forwarded to at least one of
the practices veterinary surgeons. Letters were also
published in the UK veterinary press10 and online

veterinary forums (International Society of Feline

Medicine and www.vetsurgeon.co.uk) inviting GPs to
take part. Reminder emails were sent 1, 3 and 5 weeks
after the questionnaire launch; reminders were not sent
to postal recipients owing to cost limitations. The questionnaire was open for completion from 21 August 2012
to 6 October 2012. All responses were anonymous,
although respondents who completed the questionnaire
could enter a prize draw as an incentive to encourage
questionnaire completion.
Questionnaire design
The questionnaire was hosted online using the University
of Bristol Online Survey Program. The questionnaire
took approximately 15 mins to complete and comprised
34 questions, split into five sections: general information
regarding approach to management of hyperthyroidism,
oral medical management, surgical treatment (thyroidectomy), the use of iodine-restricted dietary therapy and
respondent demographic information. Only responses
to questions pertaining to approach to management and
oral medical management are reported here; remaining
responses are reported elsewhere.11 A pilot questionnaire
of 15 veterinary surgeons was performed to test the
design, access and function of the online questionnaire.
Following this pilot study a small number of questions
were modified for functionality reasons. Most questions
were of a closed format, with a few open questions
included where respondents could enter free text. A
copy of the questionnaire and postal letter are available
from the corresponding author.
Statistical analysis
Categorical responses were summarised using descriptive statistics (percentages only). The association that the
categorical variables of perceived cost and the presence
of CKD had upon the management strategies of the
respondents was assessed by 2 tests. P values <0.05
were considered statistically significant. Statistical
analysis was performed using the SPSS 19.0 Statistics
program for Windows.

Results
Six hundred and three questionnaires were completed.
The majority of respondents were female (n = 345;
57.2%). The year of graduation of the respondents ranged
from 1960 to 2012 (median 1996); 78 (12.9%) graduated
outside of the UK and Ireland. The median estimated
percentage of the working day spent with feline patients
was 40% (range 0.25100%).
In the 6 months leading up to the questionnaire the
number of new cases of hyperthyroidism that had been
diagnosed was between one and five for 215 respondents
(35.7%), six and 10 for 213 (35.3%), 11 and 20 for 140 (23.2%),
more than 20 for 28 (4.6%) and zero for seven (1.1%).

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Journal of Feline Medicine and Surgery 16(10)

790
Considering respondents personal preference for
long-term management of hyperthyroidism, 396
(65.7%) chose oral anti-thyroid medication, 166 (27.5%)
chose thyroidectomy and 33 (5.5%) chose radioiodine.
Eight (1.3%) were either unsure or chose other options,
including homoeopathy. As the data were collected
shortly after the launch of the iodine-restricted diet,
respondents were asked to give the answer that
reflected their preference in the time before the diet
launch. When cost of treatment was eliminated as a
consideration factor, significantly more respondents
selected radioiodine (244, 40.5%), with 202 (33.4%)
choosing oral medication and 151 (25.0%) selecting
thyroidectomy as their preferred management option
(P <0.001). Respondents were asked whether they
agreed with the statement radioiodine is the gold
standard treatment for hyperthyroidism; 58.9% agreed
or strongly agreed, 19.4% disagreed or strongly disagreed, and 21.7% were not sure.
Respondents were asked to rate the importance of
factors that might influence their choice of treatment
for long-term management of hyperthyroidism in a
cat. More than 95% of respondents rated owner compliance with medication, ease of drug administration
and the presence of co-morbid disease as very important or important factors in formulating a management
plan. Table 1 summarises how respondents rated all
factors.
When asked which oral anti-thyroid medications they
preferred to use in a newly diagnosed hyperthyroid cat,
sustained-release carbimazole was favoured by 311 of
the respondents (51.6%), methimazole by 244 (40.5%)
and 39 (6.5%) had no specific preference. The unlicensed,
human form of carbimazole (Neomercazole; Roche
Products) was chosen by 9 (1.5%) respondents.

Regarding the monitoring of hyperthyroid cats during

management with anti-thyroid medication, 228 (37.8%)
respondents stated that they followed a practice protocol
(of which 204 were happy with the protocol), 224 (37.1%)
designed their monitoring protocols based upon owner
preferences and 137 (22.7%) based their monitoring protocols on published medication datasheet advice.
Fourteen (2.3%) of the respondents believed that a physical examination was the only necessary monitoring.
Respondents were asked the following question: You
have recently diagnosed hyperthyroidism in a 12-yearold cat and prescribed anti-thyroid tablets. Which of the
following parameters would you routinely use to monitor the patient and how often?. A summary of the frequency that parameters were routinely used to monitor
patients is provided in Table 2. Of all the possible monitoring parameters body weight, total T4 and renal biochemistry were the most commonly assessed by
respondents. Regarding the frequency of monitoring
parameters once the cat was stabilised, body weight was
the most commonly chosen parameter with 321 (53.2%)
respondents monitoring this every 3 months, 220 (36.5%)
every 6 months and seven (1.2%) annually. Assessment
of total T4 would be routinely monitored every 3 months
by 155 (25.7%) respondents, every 6 months by 310
(51.4%) respondents and annually by 45 (7.5%).
When asked What level of T4 do you aim for during
therapy?, 292 (48.4%) respondents reported targeting
the bottom half of the reference interval (RI), 195 (32.3%)
aimed for total T4 to be anywhere within the RI, 79
(13.1%) aimed for the top half of the RI, 11 (1.8%) aimed
for total T4 to be below the RI and three (0.5%) above the
RI. Twenty-three (3.8%) respondents stated that they did
not believe measurement of total T4 was necessary if the
cat was clinically stable.

Table 1 Importance of factors in the formulation of a long-term plan for management of hyperthyroidism in a cat, as
rated by 603 UK general practitioners in an online questionnaire (2012)
Factor

Very important /important

(number of respondents
[% of total respondents])

Owner compliance with

medication
Ease of drug administration
Co-morbid disease
Cost of treatment
Cost of monitoring
Risk of surgical complications
Age
Risk of drug side effects
Ease of referral for radioiodine
Whether pet is insured
Indoor vs outdoor cat

591 (98.0)

6 (1)

6 (1)

589 (97.7)
582 (96.5)
488 (80.9)
474 (78.6)
460 (76.3)
402 (66.7)
394 (65.3)
290 (48.1)
184 (30.5)
119 (19.7)

8 (1.3)
14 (2.3)
59 (9.8)
75 (12.4)
97 (16.1)
174 (28.9)
135 (22.4)
227 (37.6)
309 (51.2)
394 (65.3)

6 (1)
7 (1.2)
56 (9.3)
54 (9.0)
46 (7.6)
27 (4.5)
74 (12.3)
86 (14.3)
110 (18.2)
90 (14.9)

Not at all/not very important

(number of respondents
[% of total respondents])

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Not sure
(number of respondents
[% of total respondents])

Higgs et al

791

Table 2 Frequency of measurement of monitoring parameters in a recently diagnosed hyperthyroid cat as stated by
603 UK general practitioners in an online questionnaire (2012)
Parameter

Body weight
Serum total T4
Renal biochemistry*
Hepatic biochemistry
PCV
Complete blood count
Blood pressure
Urinalysis (in-house)
Urinalysis (external)

Monitoring performed in the

first 34 weeks and in months
26 of treatment (number of
respondents [overall %])

Frequency of monitoring once stabilised

(number of respondents [overall %])

34 weeks

26 months

Every 3 months Every 6 months Annually

Not specified

529
(87.7)
521
(86.4)
430
(71.3)
348
(57.7)
247
(41.0)
285
(47.3)
251
(41.6)
231
(38.3)
52
(8.6)

302
(50.1)
283
(46.9)
192
(31.8)
130
(21.6)
87
(14.4)
88
(14.6)
109
(18.1)
76
(12.6)
23
(3.8)

321
(53.2)
155
(25.7)
90
(14.9)
60
(10.0)
46
(7.6)
38
(6.3)
91
(15.1)
53
(8.8)
4
(0.7)

55
(9.1)
93
(15.4)
151
(25.0)
246
(40.8)
329
(54.6)
307
(50.9)
296
(49.1)
356
(59.0)
492
(81.6)

220
(36.5)
310
(51.4)
245
(40.6)
169
(28.0)
122
(20.2)
129
(21.4)
144
(23.9)
124
(20.6)
35
(5.8)

7
(1.2)
45
(7.5)
117
(19.4)
128
(21.2)
106
(17.6)
129
(21.4)
72
(11.9)
70
(11.6)
72
(11.9)

PCV = packed cell volume

*Renal biochemistry was stated as urea, creatinine and phosphate
Hepatic biochemistry was stated as alanine aminotransferase and alkaline phosphatase

Respondents were then asked how the presence of

CKD affected their target total T4. Two hundred and
fifty-three (42%) targeted the top half of the RI, 126
(20.9%) stated that they aimed for the bottom half, 100
(16.6%) aimed for the cat not to be hypothyroid, 59 (9.8%)
aimed for the total T4 to be above the RI, 46 (7.6%) aimed
anywhere in the RI, three (0.5%) aimed below the RI,
seven (1.1%) stated that they did not monitor for kidney
disease in hyperthyroid cats and nine (1.5%) would still
not measure total T4 is if the cat was clinically stable.
When comparing these responses to the previous question, respondents were more likely to target total T4 levels within the upper half or above the RI in the presence
of CKD (P <0.001).
Four hundred and four (67.0%) respondents indicated
that they had seen an adverse reaction to anti-thyroid
medication in the previous 12 months. Of these respondents, 185 (49.6%) stated that they had never reported an
adverse reaction to anti-thyroid medication to the
Veterinary Medicines Directorate, 136 (36.5%) had
reported up to 25% of observed reactions, 30 had
reported 2699% and only 22 (5.9%) had reported 100%
of the adverse reactions they had seen.
The 404 respondents who stated that they had seen an
adverse reaction in the previous 12 months were asked to

identify which adverse reactions they had seen. Adverse

reactions that had been seen are summarised in Table 3.

Discussion
Hyperthyroidism is the most frequently diagnosed
endocrinopathy in cats and is commonly diagnosed in
general practice.1 There is limited information regarding the standard approach used by UK GPs in managing
and monitoring this disease. This study demonstrates
that there is a strong overall preference for the use of
oral anti-thyroid medications among UK GPs for the
long-term management of feline hyperthyroidism; reasons for specific brand preferences were not investigated. When cost was eliminated from the
decision-making process, significantly more respondents chose radioiodine as their treatment of choice
(40.0% vs 5.5%). Over 75% of respondents stated that
the cost of treatment and the cost of monitoring were
important or very important factors in the choice of
treatment modality.
The effect of cost for cat owners may be less significant than practitioners believe; 51.3% of owners of
hyperthyroid cats surveyed in one study stated that
cost had no impact on their decision over which treatment to choose.9 A second survey of owners reported

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Journal of Feline Medicine and Surgery 16(10)

792

Table 3 Adverse reactions to anti-thyroid medications seen by 404/603 UK general practitioners within the 12 months
prior to the completion of an online questionnaire (2012)
Adverse drug reaction seen in the last
12 month period

Number of respondents

Percentage of all respondents experiencing

adverse drug reactions (n = 404)

Vomiting
Anorexia
Facial pruritus
Azotaemia
Anaemia
Leukopenia
Hepatic damage
Neutropenia
Thrombocytopenia
Lymphadenomegaly
Death (sudden)

279
190
181
92
48
44
39
34
34
19
4

69.0
47.0
44.8
22.7
11.8
10.9
9.6
8.4
8.4
4.7
0.9

that only 12.1% of owners of hyperthyroid cats were

using oral medication because they were concerned
about the cost of the other available modalities.8 These
studies also identified that a considerable proportion of
owners of hyperthyroid cats were not offered radioiodine as a treatment option (53.3%,9 29.7%8). This poses
the question of whether UK GPs are more concerned
regarding the effect of treatment costs than the owners
of their hyperthyroid patients. This may inadvertently
lead to reduced numbers of owners being offered referral for radioiodine despite a high proportion of respondents (58.9%) considering it to be the gold standard
treatment option. The cost discrepancy between treatment modalities may be even less significant if the
long-term cost of treatment and monitoring of patients
receiving oral anti-thyroid medications is compared to
a one-off sum for radioiodine or thyroidectomy. The
longer-term costs may be equivalent, particularly if
hyperthyroidism is diagnosed earlier in the disease
process, requiring the patient to be medically treated
for many years.12,13
Regarding the monitoring of cats receiving medical
treatment for hyperthyroidism, this questionnaire demonstrated that there is a wide variety of approaches.
Fourteen respondents stated that they did not monitor
cats receiving oral anti-thyroid medications beyond performing a physical examination. Without additional
monitoring it would impossible to optimise treatment or
identify potentially life-threatening adverse reactions or
unmasking of co-morbid conditions such as CKD or
hypertension until overt clinical signs developed.
Datasheet guidelines formed the basis for the monitoring protocols for 22.7% of respondents. The datasheets
(NOAH Compendium, www.noahcompendium.co.uk)
indicate that haematology, biochemistry and serum
total T4 should be assessed before initiating treatment
and after 3 weeks, 6 weeks, 10 weeks, 20 weeks, and

thereafter every 3 months (methimazole [Felimazole;

Dechra Veterinary Products]) and monitoring of total
T4, full haematology and liver and kidney parameters is
advised at each recommended follow up visit3, 5 and
8 weeks after initiation of treatment.and follow-up
visits every 3 to 6 months are recommended (sustained
release carbimazole [Vidalta; MSD Animal Health]). The
second datasheet specifies aiming for a total T4 in the
bottom half of the RI.
Considering target total T4, 48.4% of respondents in
this questionnaire specifically aimed for the bottom half
of the RI and only a small proportion (13.1%) aimed for
the top half. It is commonly recommended that the total
T4 of hyperthyroid cats should be maintained in the
lower half of the RI when using medical therapy;2,1216
however, there is no current evidence that maintaining a
total T4 in the upper half of the RI affects survival. It is
possible, however, that if total T4 levels are maintained
in the upper end of the RI, the cat may remain mildly
hyperthyroid if there is co-morbid disease suppressing
total T4 levels or if there is significant fluctuation of total
T4 levels.16,17
Renal biochemistry (urea, creatinine and phosphate)
was assessed by the majority of respondents both in the
early and maintenance stages of treatment, although
28.7% of respondents did not measure renal parameters
routinely after initiating treatment. It has been documented that 1551% of cats may develop azotaemia following treatment.1821 The results of this questionnaire
suggest that some practitioners may be overlooking the
unmasking of azotaemia following initiation of treatment and, subsequently, the opportunity to instigate
appropriate treatment for CKD, which could extend
survival.22
In the presence of CKD, a statistically significant
number of respondents changed their target total T4 to
the upper half of the RI or even just above the RI.

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Higgs et al

793

Previous publications have implied that the development of azotaemia following treatment for hyperthyroidism is an unwanted adverse effect of euthyroid
ism;12,19,2326 indeed, it is listed under the adverse effects
sections of one of the datasheets (sustained release carbimazole [Vidalta; MSD Animal Health]). This is now
understood to represent an unmasking of co-existing
kidney disease by restoration of GFR.12,19,24 Adams etal20
demonstrated a reduction in GFR following treatment
for hyperthyroidism; however, the degree of change in
GFR did not affect the outcome. More recent studies
have also found that the prognosis for survival in cats
developing azotaemia after treatment is unaffected
unless the cat becomes iatrogenically hypothyroid.14,21
Conversely, persistent hyperthyroidism maybe detrimental to renal function by inappropriate activation of
the reninangiotensinaldosterone system (RAAS).5,7,23
While this increases GFR, the activation of RAAS and
secondary systemic and renal afferent arterial hypertension may contribute to the progression or development
of CKD and progressive cardiac remodelling, ultimately
increasing morbidity and decreasing survival. These
recent studies suggest that the concept of maintaining an
azotaemic cat in a mildly hyperthyroid state to promote
GFR and kidney function is outdated, although the
results of this questionnaire suggest that this dogma is
still followed by some practitioners.
Only 50.9% of our respondents indicated that they
routinely (at least annually) measured blood pressure as
part of their monitoring protocol for feline hyperthyroidism. Fourteen to 22% of hyperthyroid cats are
reported to be hypertensive at diagnosis and a further
24% are described to develop hypertension de novo following the treatment for hyperthyroidism.6,7 The low
number of practitioners monitoring blood pressure may
reflect limited access to blood pressure monitoring
equipment or could be because blood pressure monitoring is not advised on the datasheet for either licensed
medication. From the questionnaire data we postulate
that a considerable proportion of hypertensive cats may
be undiagnosed before or after treatment. This may contribute to morbidity with progression of cardiac remodelling and CKD, and potentially may lead to
development of ocular and central nervous system complications.2729 Furthermore, hypertension has also been
shown to be a negative predictor of survival in hyperthyroid cats.21
Adverse reactions were suspected by 67% of respondents in the 12 months leading up to completing the questionnaire, although data were not collected on the
frequency of each type of adverse reaction. However, the
data suggest that adverse reactions remain common, in
particular vomiting and anorexia. This supports previous studies in which gastrointestinal problems were the
most frequently reported adverse effects.30,31

Less than half of the respondents (47.3%) stated that

they routinely measure a complete blood count in the
early stages of management despite datasheet guidelines. It is not possible to know whether the haematological abnormalities seen by respondents were
diagnosed on the basis of a routine monitoring test or
owing to the cat presenting with signs of illness.
Haematological changes have been reported to occur in
16% of cases, most of which are mild and clinically insignificant; however, some are severe and potentially lifethreatening, such as marked thrombocytopenia or
neutropenia.30,31 Monitoring for haematological reactions is most important in the early stages of treatment as
these reactions are usually reversible if identified
promptly.31,32 While financial consideration may be a
reason for not performing follow-up blood testing, owners should be aware of the requirement to return for reassessment if there is any deterioration in the cats
condition that could be attributed to an adverse drug
reaction.
Only a small proportion of respondents (5.9%)
stated that they had reported all the adverse reactions
associated with anti-thyroid drugs; nearly half had
never reported an adverse reaction. Given the number
of respondents who had seen adverse reactions it is
likely that the pharmacovigilance data held by the
Veterinary Medicines Directorate (VMD) and the pharmaceutical companies will be markedly skewed to
suggest a lower frequency. This is possibly owing to
cases exhibiting mild adverse reactions to anti-thyroid
medications that have been previously reported.
Additionally, it may be that practitioners are not
reporting adverse reactions if they are expected. This
may have minimal clinical significance; however, if the
true frequency of adverse reactions was known it could
change the approach to monitoring for some
practitioners.
Questionnaire-based studies are prone to bias, intentional or unintentional. We are unable to evaluate the
effect of response bias in this study owing to the method
of questionnaire distribution. The total number of GPs
contacted is not known and therefore a percentage
response rate could not be calculated and response bias
could not be assessed owing to the anonymity of completed questionnaires. We were also unable to assess
whether more than one practitioner completed the
questionnaire from each individual veterinary
practice.
Questionnaire responses might have been affected by
social desirability bias if respondents answered questions by providing what they perceived to be the clinically correct response, rather than the truthful answer.33
The questions are also unable to account for the real-life
variability of individual cases and we acknowledge that
the answers to some of the questions would vary

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Journal of Feline Medicine and Surgery 16(10)

794
dependent upon each case seen; in particular, when asking regarding target total T4 levels in the presence of
CKD, we did not specify the International Renal Interest
Society stage or stability of CKD.
The true prevalence of adverse reactions could not be
determined from the questionnaire as the question format did not evaluate the frequency of reactions per case.
We also acknowledge that these responses are reliant on
accurate recall by respondents and this may create additional inaccuracy in these data. Finally, the effect of dietary therapy and transdermal methimazole on GPs
favoured management is unknown; the iodine-restricted
diet (Hills y/d) had been available for only short period
at the time of questionnaire and was not included in general management questions.

Conclusions
There is a preference for the use of anti-thyroid medications in the management of feline hyperthyroidism in
UK general practice over potentially curative treatment
options. This preference appears to be strongly influenced by cost considerations. Although most GPs do
perform some sort of regular monitoring of hyperthyroid cats receiving oral medications, common co-morbid
diseases, including hypertension and renal disease, may
be undiagnosed and unmanaged in some cases.
Recent information regarding the management of
azotaemic cats with hyperthyroidism relating to optimising total T4 levels and detection of hypertension
does not appear to be widely implemented in general
practice. Azotaemia may still be considered by some
practitioners as an adverse reaction to medication or
treatment in general rather than evidence that uncontrolled hyperthyroidism may be masking CKD.
Finally, the protocol for monitoring for adverse effects
varies significantly between practitioners; however, this
study demonstrates that adverse effects may be more
common than indicated by data held by the VMD.

10
11

12

13

Acknowledgements
We would like to thank all those who completed this questionnaire, the editors of The Veterinary Record, VetSurgeon.org and
the International Society of Feline Medicine for advertising this
questionnaire, as well as The Langford Trust and Langford
Veterinary Services for supporting the study.

Conflict of interest The authors do not have any conflicts

14

15

of interest to declare.

Funding This study received funding from The Langford Trust,

a registered charity and Langford Veterinary Services for prize
incentives and postage. Jane Murray is funded by Cats Protection.

16

17

References
1 Edinboro CH, Scott-Moncrieff JC, Janovitz E, etal. Epidemiologic study of relationships between consumption of

18

commercial canned food and risk of hyperthyroidism in

cats. J Am Vet Med Assoc 2004; 224: 879886.
Peterson ME, Melian C and Nichols R. Measurement of
serum concentrations of free thyroxine, total thyroxine,
and total triiodothyronine in cats with hyperthyroidism
and cats with nonthyroidal disease. J Am Vet Med Assoc
2001; 218: 529536.
Melendez LD, Yamka RM and Burris PA. Titration of
dietary iodine for maintaining normal serum thyroxine
concentrations in hyperthyroid cats. J Vet Intern Med 2011;
25: 683.
Melendez LM, Yamka RM, Forrester SD, et al. Titration of dietary iodine for reducing serum thyroxine
concentrations in newly diagnosed hyperthyroid cats.
J Vet Intern Med 2011; 25: 683.
Boag AK, Neiger R, Slater L, et al. Changes in the glomerular filtration rate of 27 cats with hyperthyroidism
after treatment with radioactive iodine. Vet Rec 2007; 161:
711715.
Morrow L, Adams V, Elliott J, et al. Hypertension in hyperthyroid cats: prevalence, incidence and predictors of its
development. J Vet Intern Med 2009; 23: 699.
Williams TL, Elliott J and Syme HM. Renin-angiotensinaldosterone system activity in hyperthyroid cats with and
without concurrent hypertension. J Vet Intern Med 2013; 27:
522529.
Caney SMA. An online survey to determine owner experiences and opinions on the management of their hyperthyroid cats using oral anti-thyroid medications. J Feline Med
Surg 2013; 15: 494502.
Boland L, Murray JK, Bovens CPV, et al. Survey of owners
perceptions of radioiodine treatment of feline hyperthyroidism. J Feline Med Surg 2014; 16: 663670.
Higgs P and Hibbert A. Managing hyperthyroidism in
cats. Vet Rec 2012; 171: 225226.
Higgs P, Murray JK and Hibbert A. A survey of management
strategies of the hyperthyroid cat in UK general practice.
Proceedings of the British Small Animal Veterinary Association annual congress; 2013 April 47; Birmingham, UK.
Bucknell DG. Feline hyperthyroidism: spectrum of clinical presentions and response to carbimazole therapy. Aust
Vet J 2000; 78: 462465.
Wakeling J, Elliott J and Syme H. Evaluation of predictors
for the diagnosis of hyperthyroidism in cats. J Vet Intern
Med 2011; 25: 10571065.
Williams TL, Elliott J and Syme HM. Association of iatrogenic hypothyroidism with azotemia and reduced survival time in cats treated for hyperthyroidism. J Vet Intern
Med 2010; 24: 10861092.
Broussard JD and Peterson ME. Changes in clinical and
laboratory findings in cats with hyperthyroidism from
1983 to 1993. J Am Vet Med Assoc 1995; 206: 302305.
Wakeling J, Moore K, Elliott J, et al. Diagnosis of hyperthyroidism in cats with mild chronic kidney disease. J Small
Anim Pract 2008; 49: 287294.
Peterson ME, Graves TK and Cavanagh I. Serum thyroid
hormone concentrations fluctuate in cats with hyperthyroidism. J Vet Intern Med 1987; 1: 142146.
Riensche MR, Graves TK and Schaeffer DJ. An investigation of predictors of renal insufficiency following

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015

Higgs et al

19

20

21

22

23

24

25

26

795

treatment of hyperthyroidism in cats. J Feline Med Surg

2008; 10: 160166.
Graves TK, Olivier NB, Nachreiner RF, et al. Changes in
renal function associated with treatment of hyperthyroidism in cats. Am J Vet Res 1994; 55: 17451749.
Adams WH, Daniel GB, Legendre AM, et al. Changes in
renal function in cats following treatment of hyperthyroidism using I-131. Vet Radiol Ultrasound 1997; 38: 231238.
Williams TL, Peak KJ, Brodbelt D, etal. Survival and the
development of azotemia after treatment of hyperthyroid
cats. J Vet Intern Med 2010; 24: 863869.
Elliott J, Rawlings J, Markwell P, et al. Survival of cats with
naturally occurring chronic renal failure: effect of dietary
management. J Small Anim Pract 2000; 41: 235242.
Adams WH, Daniel GB and Legendre AM. Investigation
of the effects of hyperthyroidism on renal function in the
cat. Can J Vet Res 1997; 61: 5356.
DiBartola SP, Broome MR, Stein BS, et al. Effect of treatment of hyperthyroidism on renal function in cats.
J Am Vet Med Assoc 1996; 208: 875878.
Becker TJ, Graves TK, Kruger JM, etal. Effects of methimazole on renal function in cats with hyperthyroidism. J Am
Anim Hosp Assoc 2000; 36: 215223.
Milner RJ, Channell CD, Levy JK, et al. Survival times
for cats with hyperthyroidism treated with iodine 131,

27

28

29

30

31

32

33

methimazole, or both: 167 cases (19962003). J Am Vet Med

Assoc 2006; 228: 559563.
Elliott J, Barber P, Syme H, et al. Feline hypertension: clinical findings and response to antihypertensive treatment
in 30 cases. J Small Anim Pract 2001; 42: 122129.
Brown S, Atkins C, Bagley R, et al. Guidelines for the
identification, evaluation, and management of systemic
hypertension in dogs and cats. J Vet Intern Med 2007; 21:
542558.
Bartges JW, Willis AM and Polzin DJ. Hypertension and
renal disease. Vet Clin North Am Small Anim Pract 1996; 26:
13311345.
Scott-Moncrieff JC. Current concepts in diagnosis and
treatment of feline hyperthyroidism. Proceedings of
the North American veterinary conference; 2010 Jan 16;
Orlando, USA.
Peterson ME, Kintzer PP and Hurvitz AI. Methimazole
treatment of 262 cats with hyperthyroidism. J Vet Intern
Med 1988; 2: 150157.
Behrend EN. Update on drugs used to treat endocrine diseases in small animals. Vet Clin North Am Small Anim Pract
2006; 36: 10871105.
Boynton PM and Greenhalgh T. Hands-on guide to questionnaire research selecting, designing, and developing
your questionnaire. BMJ 2004; 328: 13121315.

Downloaded from jfm.sagepub.com at The Royal Veterinary College on January 20, 2015