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Irish Veterinary Journal Volume 61 Number 1

Feline weight loss: Don’t write off


that thin old cat
Dr Andrew Mackin BVSc BVMS MVS DVSc DSAM FACVSc DipACVIM, Associate Professor, and Dr Hugh
G. Ward, Chair of Small Animal Medicine, Mississippi State University College of Veterinary Medicine.
USA.

Weight loss in cats can seem daunting to investigate. However, using a structured diagnostic approach, it is usually possible to rapidly and relatively cheaply narrow down the
causes of weight loss at least to either a single organ or a single disease process.

Weight loss is a very common presenting complaint in causes of weight loss in cats, and these will be emphasised
both cats and dogs. As a presenting sign, it can initially in this paper. Some causes of weight loss, however, can be
seem more than a little daunting to investigate, because remarkably difficult to diagnose: over the past few decades,
practically every disease listed in medical textbooks is the authors have met many hundreds of different (and
capable of producing weight loss. However, using a sometimes remarkably obscure) causes of feline weight loss.
structured diagnostic approach, it is usually possible Weight loss is often reported by owners as a primary
to rapidly, and relatively cheaply, narrow down the concern during a clinic visit. Occasionally, however, weight
causes of weight loss at least to either a single organ (for loss is not noticed by the owner (especially in fat or long-
example, ‘liver disease’) or a single disease process (for haired cats), and is first noted by the veterinarian during
example, ‘cancer’) or, ideally, to a very specific aetiology a routine visit. Good clinical records are very helpful here:
(hepatocellular carcinoma, for example). A work-up for even subtle drops in weight will be noticed if the cat’s
weight loss should initially be targeted at what is cheap weight is recorded at every clinic visit. A drop in weight
and easy to diagnose (diseases that can found by history, of more than 5% to 10% should be considered to be a
physical examination, routine bloodwork and radiographs) potentially important early clue to significant disease, and
and what is common (horses rather than zebras). In my should be investigated, except in cats on diets or in cats that
experience, there are about a dozen or so relatively common have had a marked increase in physical activity.

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Irish Veterinary Journal Volume 61 Number 1

Obtaining a thorough history, in the authors’ opinion, is the after a simple diagnostic work-up has excluded most
single-most important diagnostic aid performed in working common diseases that can cause anorexia and weight loss.
up a weight loss cat. Obviously, history-taking should
be comprehensive, and may reveal clear-cut clues such Physical examination
as vomiting or coughing, but the first priority of history Physical examination in cats with weight loss should be
taking should be to divide weight loss cats into three main very thorough and, as well as a standard examination
categories based on the owner’s perception of appetite: (including temperature), should include:
1. Decreased appetite with decreased food intake; • A thorough oral examination (look under the tongue for
2. Normal to increased appetite with normal to increased string or thread)
food intake; • Thyroid palpation (up to 10% of hyperthyroid cats have
3. Normal to increased appetite with decreased food intake decreased appetites)
due to an inability to eat. • Respiratory and cardiac auscultation
• Abdominal and lymph node palpation
The diagnostic approach to each of these three categories • Palpation of the spinal column, muscles, bones and
of weight loss is very different, and each category will joints, looking for painful foci
therefore be considered separately. Weight loss due to • Cursory ophthalmologic and neurologic examination
decreased appetite is by far and away the hardest form of Often, a physical examination will offer clues that suggest
weight loss to investigate, which is unfortunate, because it is a very clear-cut diagnostic direction, such as a palpable
also easily the most common. abdominal mass, fever or jaundice. As with history-taking,
any useful clues should be aggressively investigated.
Weight loss with decreased appetite
Practically any disease or condition that a cat can get Routine blood work
can lead to decreased appetite and subsequent weight Routine blood work (and urine and faecal analysis) is very
loss. Fortunately, most causes of weight loss with valuable in cats with weight loss, as it offers a reasonably
a decreased appetite can be determined by history, cost-effective means of casting a wide net, and detecting
physical examination, routine bloodwork and whole-cat most of the important diseases that will be missed on
radiographs. history and physical examination. The authors’ standard
work-up in cats with weight loss includes:
History a. Hematology (complete blood count, including
The authors commonly use a ‘problem-orientated approach’ examination of a blood smear)
to making diagnoses in challenging medical cases. One of b. Serum biochemistry, including electrolytes (sodium and
the key tenets of a problem-orientated approach is to try potassium), calcium and creatine phosphokinase (CK or
to get away from ‘problems’ that are minimally helpful CPK), but not including measurement of amylase and
because they are caused by a myriad of different diseases lipase (which have not been well-validated in the cat)
(e.g., anorexia, weight loss or fever), and instead identify c. Urinalysis
problems that have a limited range of causes and a simple, d. Fecal flotation
structured diagnostic approach (dyspnoea, for example). A e. T4 (cats over six to eight years old)
very thorough history may uncover one or more specific f. FeLV and FIV
clues that will make the diagnostic approach more clear-
cut, including: The above testing is, in the authors’ opinion, a very good
• Regurgitation, vomiting or diarrheoa investment, because it identifies many important causes
• Coughing, sneezing or dyspnoea of anorexia and weight loss in cats, both common and
• Polyuria and polydipsia uncommon, including:
• Difficulty urinating or defaecating • Chronic renal failure
• Neurologic signs, syncope or seizures • Liver diseases
• Some gastrointestinal disorders (protein-losing
Each of the above problems, when identified, will lead to a enteropathies, for example)
focussed diagnostic approach. Coughing, for example, will • Hypercalcaemia (most commonly paraneoplastic, but
lead to thoracic radiographs and a respiratory work-up. also idiopathic and secondary to hyperparathyroidism)
Duration of inappetance (decreased appetite) and anorexia • Diabetic ketoacidosis
(complete loss of appetite) should be determined, as should • Hyperthyroidism
any potential triggers. Owners very commonly associate loss • Hypoadrenocorticism
of appetite and weight loss with a behavioural trigger, such • Severe anaemia
as a death in the family, loss of companion pets, addition • Leukaemia
of new animals, or a change in address. Although such • FeLV and FIV
behavioural triggers of decreased appetite in cats certainly • Blood parasites
do occur, and should not be ignored, the authors believe • Inflammatory diseases (a marked inflammatory
that behavioural causes of inappetance are best pursued leukogram)

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• Urinary tract infection cases, four possible causes are most likely:
• Intestinal parasites i. Neoplasia
Undiagnosed cancer is probably the most important and
Each of the above findings often will provide a specific common cause of weight loss in cats that provide no
diagnosis, such as hyperthyroidism, chronic renal failure diagnostic clues on first examination. Cancer cachexia
or diabetic ketoacidosis, or at the very least suggest a (weight loss associated with neoplasia) is a paraneoplastic
structured diagnostic approach. Elevated liver enzymes disease that can sometimes be triggered by very small
and hyperbilirubinemia, for example, suggest that the neoplasms. A very thorough search for cancer is indicated
liver should be investigated by imaging and aspirates and in problem weight loss cats, including repeating a complete
biopsies. Routine blood screening tests, however, should be physical examination, re-examining radiographs carefully
interpreted with caution, because a number of non-specific and performing abdominal ultrasonography.
findings that do not suggest a specific disease process are ii. Gastrointestinal disease
often found in unwell cats, including: Sometimes, gastrointestinal diseases in cats can be
remarkably hidden, and can cause anorexia and weight loss
− Stress leukogram without vomiting, nausea or diarrhoea. Gastrointestinal
A mild mature neutrophilia, eosinopenia and lymphopaenia diseases that can cause chronic weight loss in the absence
are common in cats with practically any chronic disease, of obvious gastrointestinal signs include; inflammatory
and do not help localise the process. bowel disease, chronic partial intestinal obstructions
− Mild anaemia (such as ‘string gut’), gastrointestinal neoplasia (especially
Anaemia of chronic disease (hematocrit of 20 to 25%, lymphosarcoma) and chronic pancreatitis. Most of these
with minimal regeneration) is very uncommon, and will provide useful clues with abdominal ultrasonography
diagnostically non-specific, in unwell cats. performed by an experienced ultrasonographer. On
− Mild hypoalbuminaemia occasions, the authors have made a diagnosis with
Similarly, albumin (a ‘negative acute phase protein’) is further gastrointestinal testing, including feline pancreas-
commonly mildly decreased in cats that are chronically specific lipase, barium series, endoscopy of the upper
unwell for any reason. gastrointestinal tract and exploratory laparotomy.
− Mild to moderate hyperglobulinaemia iii. Brain disease
Any chronic disease (infectious, inflammatory or neoplastic) Intuitively, cats with brain disease severe enough to cause
can lead to an increase in globulins, since globulins are anorexia would be expected to show obvious neurologic
composed of both immunoglobulins and acute phase disease such as altered mentation, seizures, stupor or
proteins, which both tend to be stimulated in chronic blindness. Usually, this is the case, although signs of brain
diseases. Certainly, hyperglobulinemia, in the absence of disease can occasionally be subtle. Rarely, however, a
other consistent clinical findings, does not indicate a specific small lesion near the hypothalamus or midbrain has the
disease process such as FIP. potential to affect the appetite centre, and cause anorexia
− Mild to marked hyperglycaemia in the absence of neurologic signs. A thorough neurologic
Acutely stressed cats, either due to illness or psychological examination, including a retinal examination, should be
stress, can have marked increases in blood glucose (and performed in all problem weight loss cats. As a diagnostic
some glucose spillover into the urine) due to stress alone. test of ‘last resort’, brain imaging (CT scan or MRI) may be
Without accompanying clinical signs, this should not be warranted.
automatically assumed to indicate diabetes mellitus. iv. Behavioural disorders
− Mild to moderate azotaemia Behavioural disorders are most likely in anorexic cats in
Unwell cats commonly will become dehydrated, and mild which no other cause for anorexia has been found. In the
azotaemia with concentrated urine is an expected and authors’ experience, behavioural disturbances usually cause
non-specific consequence. Azotaemia in the presence of only transient or mild anorexia. If inappetance is severe
poorly concentrated urine, on the other hand, suggests and persistent, a severe underlying disorder such as hepatic
more specific disease processes such as renal failure, lipidosis should be suspected.
hyperthyroidism or hypercalcaemia.
Weight loss with normal to increased appetite
Radiography In contrast to weight loss with a decreased appetite, causes
Whole-cat radiographs are particularly useful in cats with of weight loss with a normal to increased appetite are few.
weight loss to detect abnormalities not detected by blood The list of possible causes is short and relatively easy to
work, such as abdominal or thoracic neoplasia, pleural investigate:
effusions, or pneumonia. Hyperthyroidism
In the authors’ experience, hyperthyroidism is the most
Problem cases common cause of weight loss with an increased appetite
Uncommonly, the above thorough and structured work- in older cats. Usually, history and physical examination
up will provide no useful clues in the inappetant cat with reveal many more clues to hyperthyroidism, including
weight loss. In the authors’ experience, in these problem polydipsia/polyuria, hyperactivity, cold-seeking behavior,

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Irish Veterinary Journal Volume 61 Number 1

excessive grooming, weakness, a palpable thyroid nodule inflammatory bowel disease, intestinal lymphoma,
and tachycardia (often with a heart murmur or a gallop intestinal parasitism and intestinal microbial infections
rhythm). Blood work may reveal mild polycythaemia and with organisms such as Salmonella, Giardia, Cryptosporidium
elevated liver enzymes, and urinalysis may reveal dilute and Tritrichomonas fetus. Indicated diagnostic tests include
urine. trypsin-like immunoreactivity (the preferred test for EPI),
Resting total T4 is usually elevated in hyperthyroid cats, faecal flotation, faecal culture for specific faecal pathogens,
making diagnosis easy. Generally, T4 is low or low normal direct fluorescent assay for Giardia and Cryptosporidium,
in cats with weight loss, so even a high normal T4 in a in pouch culture or PCR for Tritrichomonas, abdominal
cat with weight loss should make the clinician suspect ultrasonography and gastrointestinal endoscopy.
hyperthyroidism. Often, when T4 is repeated (a day or two
or a week or two later) in weight loss with high normal Cancer cachexia
T4s, the repeat T4 will be elevated, confirming a diagnosis Cancer cachexia usually causes weight loss associated with
of hyperthyroidism. Uncommonly, more specialised tests a decreased appetite. Uncommonly, however, cancer can
such as free T4, T3 suppression or thyroid scintigraphy will lead to an efficient utilisation of nutrients and weight loss
be needed to confirm the diagnosis. despite a good appetite. Once more common disorders,
such as hyperthyroidism and diabetes, have been ruled out,
Diabetes mellitus a thorough search for cancer is indicated in thin cats with
Like hyperthyroidism, diabetes mellitus is one of the few good appetites.
feline diseases that combines weight loss with polyphagia
and polyuria/polydipsia. Diagnosis of diabetes is usually Changes in management practice
not a challenge, since the findings of a combination of Although more common in cats than dogs, occasionally
hyperglycaemia and glucosuria (and, often, ketonuria) in major changes in owner management practice (especially,
a cat with consistent clinical signs establish the diagnosis. changes in diet or exercise) can lead to unexpected
Marked stress hyperglycaemia and resultant glucosuria can weight loss. Owners should be carefully questioned for
occasionally be mistaken for diabetes. In instances when major changes in management of their cats: for example,
the diagnosis is at doubt, further tests such as serial testing surrounding an older cat with new and active playmates,
of blood glucose to establish persistent hyperglycaemia or moving indoor cats outdoors (especially in winter),
measurement of either serum fructosamine or glycosylated restricting food intake, or switching to a more energy-
haemoglobin will confirm a diagnosis of diabetes mellitus. restricted diet.
Thin cats with increased appetites are typically very
Malassimilation rewarding to investigate because, with the uncommon
Gastrointestinal diseases causing malassimilation exception of some cancers, most causes are very treatable.
(maldigestion or malabsorption) lead to inefficient
utilisation of nutrients, and can lead to weight loss Inability to eat despite a good appetite
in the face of an increased appetite. Such diseases Occasionally, cats with weight loss have decreased food
usually cause obvious gastrointestinal signs such as intake despite a ravenous desire to eat. Affected cats have
vomiting or diarrhoea, and are often associated with a disease that does not affect their appetite, but impairs
hypoalbuminaemia. Gastrointestinal diseases that the their ability to prehend or swallow food. Such disorders
authors have seen cause weight loss despite a healthy are usually obvious based on careful history-taking and
appetite include: exocrine pancreatic insufficiency (EPI), physical examination. Often it helps to watch the cat

Figure 1: Disorders that can restrict a cat’s ability to − Oesophageal strictures


prehend and swallow food, despite the persistence of − Oropharyngeal or oesophageal foreign bodies or tumours
hunger.
• Masticatory muscle dysfunction
• Oral pain − Masticatory muscle myositis
− Severe dental or periodontal disease, including tooth − Polymyositis
root abscessation − Trigeminal nerve paralysis
− Gingivitis or stomatitis
− Mandibular or maxillary fractures • Temporomandibular disorders
− Oral ulceration or eosinophilic granuloma complex − Temporomandibular joint luxation, fracture or arthritis
− Oral neoplasia − Mandibular tumours

• Pharyngeal or oesophageal dysphagia • Neuromuscular disorders


− Pharyngeal paralysis − Peripheral neuropathies
− Megaoesophagus − Neuromuscular disorders such as botulism, tick paralysis
− Oesophagitis and tetanus
− Myopathies

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attempt to eat food. Difficulties with food prehension or Palatable foods


swallowing due to oral, jaw, pharyngeal or oesophageal Sometimes, trying more palatable food options, such as
pain or dysfunction are usually obvious. Often, a definitive very mildly warming food (but only to body temperature),
diagnosis can then be made simply by a thorough oral trying canned food instead of dry food, trying fishy foods,
(sedation or light anaesthesia is often needed in painful or or supplementing with tempting flavors (avoid garlic,
fractious cats) or neuromuscular examination. Disorders which can cause haemolytic anaemia) can get a cat to eat.
that can restrict a cat’s ability to prehend and swallow Cats with a poor sense of smell (cats with nasal disease, for
food, despite the persistence of hunger, include: oral example) may respond favourably to more smelly foods.
pain, pharyngeal or oesophageal dysphagia, masticatory
muscle dysfunction, temporomandibular disorders or Appetite stimulants
neuromuscular disorders (Figure 1). Medical appetite stimulants include diazepam (Valium)
and cyproheptadine (Periactin). Such drugs are often
Supporting the cat with weight loss at least temporarily effective, but should be used with
The most effective means of treating a cat with weight caution, especially long-term, since adverse drug side
loss is to diagnose and treat the underlying disease that is effects such as hepatopathies are sometimes reported.
causing the weight loss, and this should always be a high Unfortunately, less intensive treatments such as hand
priority. However, other supportive measures that can be feeding, palatable foods and medical appetite stimulants
considered include: are usually only highly effective in cats with either
behavioural problems or ‘mild’ diseases that should be
Hand feeding well on the road to recovery. The authors usually reserve
Cats can sometimes be tempted to eat with gentle relying on such treatments for cats with problems in
stroking and hand feeding. Hand feeding should never which they should be ‘well enough’ to eat, but for some
be overdone to the point of force feeding. Cats vigorously reason appetite is still down. If inappetance persists,
resist force feeding, and often develop lifelong aversions either a serious illness is being missed, or more aggressive
to food that they were forcibly fed. feeding methods are needed.

Nutritional support
Aggressive nutritional support is indicated in cats that
have lost more than 5% of their body weight acutely, more
than 10% of their weight chronically, or that have not
eaten for more than three to five days. Many nutritional
supportive modalities are available, but ones commonly
used in the authors’ hospital include:
• Nasoesophageal tube feeding
• Oesophagostomy tube feeding
• Gastrostomy tube feeding (usually placed via
endoscope)
• Total or parenteral intravenous nutrition

While such supportive modalities are often temporary


(two to five days), on occasion oesophagostomy or
gastrostomy tubes can be used to maintain thin cats for
weeks or even months.

This article was first presented at the 2006 VICAS Winter


Conference. This year’s Winter Conference takes place in the
Heritage, Killenard, Co. Laois from January 25 to 27. For
more information, contact Ovation on 01 280 2641 or email
vicas@ovation.ie.

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