Hyperthyroid, and radioiodine centres

[MissMidwinter]

Hi everyone

I'm new here and wanted to ask whether anyone has any specific experience and/or can recommend a radioiodine centre in the UK. Our purry lovebug Chessie is hyperthyroid and sadly can't have the medication: she had a bad reaction to Felimazole and developed severe acute liver problems. Fingers crossed, she's recovering from that, but assuming she recovers enough, we need to work out the next step.

As she's an indoor cat and lives for her cuddles but can be very nervous around strangers, we initially looked for the centre with the shortest stay. The Hyperthyroid Cat Centre at Wetherby (5 hours from us!) claims to have the shortest minimum stay at just 4 days - but of course, that's not to say 4 days is the norm, and they were cagey about saying what their average stay is. I know everyone worries about their cat being away from home, but our littl'un can be a bit highly strung so this is a really, really big deal for us.

There's another problem, which is that she has a couple of painful teeth that are making it hard for her to eat. She is managing a little on her own, with the help of Mirtazepine (appetite stimulant); on vet's advice, we're supplementing that with daily assisted feeds (she actually likes this!) to keep her weight up. But I'm so worried about her being able to eat and drink while in the unit, and what they could do to help her, if anything, as they say can't intervene after radioiodine treatment. The thyroid issue makes her an anaesthetic risk, so she can't have a dental until her thyroid is controlled. So, although in every other way she is a lively, happy, glossy 14 year old, we're in a catch 22. I'm terrified that she'd go downhill and they couldn't help her. Having almost lost her to liver failure, I don't even want to think about how that would feel.

That aside, assuming that we're lucky enough to find somewhere to take her for the treatment, does anyone have any experience with the Wetherby centre or any of the others?

Thanks in advance,

C

[Mollycat]

I seem to remember someone on here used Wetherby so I'm sure they will be along with some helpful experience for you very soon.

My girl is also very timid and medication was out of the question, for trauma reasons. We are in the South-west and our nearest centre is Langford vet school and hospital. It's world renowned as a treatment centre, not necessarily for radioiodine specifically, but it is a pretty awesome place. Their stay is 12-14 days. The list of tests they do is awesome, they are also more expensive than some (3 years ago I paid £2,500 including a 2 day stay for tests 4 weeks pre treatment when some centres were as low as £1,800, but I believe you get what you pay for).

Best thing I can suggest is ring the centres you are prepared to travel to, I think there are still only a dozen in the UK so not a lot of calls! and discuss the feeding issue with them. Once the injection has been given the cat is highly radioactive and staff cannot risk their health with extended contact, and you are not allowed in, but if need be they will give appetite stimulants and different foods to encourage eating.

The reason for longer stays is for your and your family's safety, the cat comes back still eliminating radioactive particles in their pee, poop and in general contact with you at a level that means contact with you must be restricted for a while. I had another cat and dog in the house, if you have other pets and children that will be hard to keep away, a longer stay is good.

Just one other thing - my girl was diagnosed hyperthyroid following what I can only describe as a crash where she very quickly became very ill. Her bilirubin was high, platelets almost nothing, and ALT liver enzyme higher than the vet would expect for just hyperthyroidism. She had yellow stuff coming out of both ends, she was not well. Following treatment her liver function came back to normal gradually and we have no idea what caused her initial crash.

We used the Hills y/d special thyroid food to control her levels before her treatment and it really worked, she was down from T4 over 70 to 30 so well in the normal range, and back up when she went back on normal food ready for the injection. You can also get a gel to apply to the skin if tablets or liquid meds are a problem.

Also be aware of the risks, and if you really don't want a stay in hospital, be aware that the other option of surgery has a 70% chance of needing a second operation and either lifelong meds or a 30% chance of extra thyroid material deep in the chest where they cannot operate which is often the material that is going haywire. Read everything you possibly can find, make a list of all the questions that you still have, and ask the radioiodine centres direct about everything - in my book this is a really serious and expensive undertaking and if they don't have time to talk to prospective patients, I would not trust them with my cat. You are not wasting anyone's time, you are doing vital research to make sure you make the right decisions for your cat, and they should understand that and do everything they can to help you.

eta: I also asked the important question I think you're probably considering too: What happens if we do nothing? Blood pressure goes up and can cause blindness and heart failure, so it's not an option. But out of the 4 treatment and management options in front of you, radioiodine is the gold standard for suitable cats. Maybe get a second opinion on her teeth, if her thyroid is managed and under control with drugs or diet I don't know why anaesthesia is out of the question.

Langford link: https://www.langfordvets.co.uk/small-an ... ve-iodine/

[fjm]

I used the Wetherby Centre for Pippin's HT and found them excellent. Pippin was a very easy cat, so I had no qualms about leaving him there - I was even able to take two week's supply of his home cooked food portioned and frozen to avoid sudden change of diet. They are hugely experienced and utterly focussed on cats in general and HT in particular, and will do whatever is necessary to keep them eating. As Molly has explained the length of stay needed very much depends upon your own circumstances and how well you can manage the essential quarantine period. I chose to leave Pip for the full two weeks included in the cost of the treatment as the regular updates I received made it clear that he was settled and eating well. I feared he might be more anxious shut in one room at home for 4 weeks, and was unsure of my ability to keep him there for the time needed. As I had dogs who would happily raid the litter tray good management was absolutely essential, even without the risks should he get outside. It turned out to be easier than I had feared to keep him safely in the spare bedroom, and we got through the second two weeks at home without problems.

Four days is the minimum, but I don't think they will let the cat leave until the radioactivity has fallen to a comparatively safe level, and that will vary from one individual to another. The earlier she comes home the more stringent you would need to be about contact and other precautions, so there is a lot to consider - if she loves cuddles from her family she may be confused and upset if they have to be withheld. I too would try to get the teeth sorted first if there is any way it can be done safely - you could discuss whether tube feeding would be an option immediately after the radioiodine treatment but I suspect not.

[Mollycat]

I was just re-reading some of Langford's detailed info and apparently the minimum stay is set by the local authority and their interpretation of the guidance on radioactivity. Home isolation is really important so that the full 4 weeks of precautions are observed for everyone else's safety, and yes it is incredibly hard when all you want to do is hug them and smother them in kisses after surviving all that stress, and it really is hard but well worth it.

There are a few old discussion threads about it on here where you will see the mental torture we go through. Molly did not settle and I was an absolute wreck the whole time she was gone, but I had no realistic alternative and as soon as it was done that's it, it's history.

[MissMidwinter]

Thanks both, Mollycat and fjm!

We're in a bit of a catch 22 as Chess can't have Methimazole, the active ingredient in all the proprietary hyperthyroid meds available. It's fine for most cats, at least in the short-medium term, but it almost killed her after only 3 weeks. She's still recovering, but fingers crossed, things are looking good on that front. Unfortunately uncontrolled hyperthyroidism, even for a dental, makes her an unacceptable anaesthetic risk unless in an emergency, or if there's absolutely no alternative. We had discounted the dietary option as she is a picky eater at the best of times, plus we have another cat and can't really feed them separately - but, as we are now assist feeding Chessie to make up her calories, it might be an option to reduce her T4 levels somewhat in the interim. She's a very odd girl and quite likes the syringe feeding (she thinks it's a teat!) - which is keeping her going, but of course centre staff can't do that for her after RAI. So we and the vet, who's a senior consultant and has worked in an RAI unit, are all hoping to get her out asap. No centre will discharge them until radiation levels have reduced ... but by contrast hyperthyroid humans receive a very much larger dose of RAI and are allowed home to their family the same day. We are having to be pragmatic about it; she doesn't go outside, we don't have children at home, and do have a spare room which we can use. Not expecting it to be easy, but you never know! On the other hand, if by some miracle she's doing OK in hospital, then fine.

Fortunately she has been managing to eat a bit on her own with appetite stimulant (Mirtazepine), so we hope that might be enough to get us through a short hospitalisation.

The tooth problem is frustrating as she only had a dental a year ago, and the vet suggested that he had left a couple of teeth that might need further attention ...

Prior to having Felimazole she was - OK, hyperthyroid - but a happy, cheeky, active cat. Losing weight and muscle mass rapidly though, and she's always been tiny, so now decidedly thin. So RAI really is our only option - nerves (hers and ours!), separation anxiety, concerns about eating and dauntingly long journeys aside. It feels like RAI or bust.

One other complicating factor is that we may be in for a wait for treatment due to problems with availability of the radioactive isotopes, when obviously both teeth and thyroid levels are only going to get worse in the interim. So, again, it may be worth revisiting the special diet option.

[Mollycat]

I didn't think Molly would take the y/d but she did, it's a soft mousse-like pate so you may even be able to give it using the assisted feed way, I don't know, or have her lick it from your fingers. You have my complete sympathy on both fronts, the looming treatment, and the complex needs cat as well. Sounds like you have an understanding and supportive vet which is 90% of the battle.

As for the isolation period, I signed the discharge agreement to no more than 10 minutes contact and no sleeping in the bedroom, knowing full well I wasn't going to stick to it at all, and I admire people who do it to the letter because I couldn't, and I think they know that when they ask you to sign and are only covering themselves by your signature that you have been advised.

[MissMidwinter]

Yes ... we've just discussed whether we might be able to reduce T4 levels enough to have the dental by ONLY feeding her y/d by the syringe route. Good in one way that we have an opportunity to control it like that, but I don't want to put her off eating herself as she is managing a little while on Mirtazepine. y/d is difficult otherwise as we have the other cat, and neither of them are the sort to scoff a bowl of food and walk away - they like to graze all day.

But, having been ringing RAI centres this afternoon and finding a) some aren't taking referrals at all at present, due to non-availability of RAI and b) so far most are saying they would not intervene if a cat wasn't eating or drinking, after RAI. One receptionist even told me their vets would not enter the isolation unit under any circumstances and would probably not even put a cat to sleep if suffering ... that's not really a risk I'm prepared to take. I asked whether they might give an appetite stimulant for a cat that wasn't eating and she said they'd put it in the food.

My feeling is that we might not find an RAI centre that will take her, but vet is currently against surgery as too risky - and I understand why he's saying that.

[Mollycat]

Good grief how could anyone entrust their beloved pet to people who would watch them suffer on a camera and do nothing! Understandable that they have to keep staff safe who work there all the time but you'd think they might have better personal protection to cope with special cases. Makes you wonder how they put their food and water in and change their trays? Sounds like a receptionist overdramatising to me. At Langford I thought when I left her that she would get a couple of days to settle, then have the injection, then be left in peace for the 10 days or so. But then I got updates saying she was moved from Hot Cat Ward to Cool Cat Ward and more pre-discharge tests. I don't remember exactly how long she was on Hot Cat Ward and I'm assuming those were the days they didn't handle her but they still fed her and did her litter.

[MissMidwinter]

To be fair, she was just the receptionist and has taken a message to ask the vet in charge of the unit to call me back - which they might not do, as we don't have an actual referral yet. But, what I'm trying to get out of them is, if an otherwise well cat needs an intervention like an appetite stimulant, would they be willing to give it it - and if not, are they saying that they'd just leave them to wither away?

Mirtazepine can be given via injection or ear gel, so no need for prolonged contact, or needing to get inside the mouth.

Sorry to keep asking questions, you've been so helpful already - but, how long was your girl on the "hot" ward for?

[Mollycat]

I've had to go back through social media, it appears she moved from Hot to Cool on either the Thursday or the Friday and came home the following Tuesday, and she went in on a Tuesday and had her injection on that Thursday, so that makes it a week on HOT.

However on the subject of food:

All being well this should be the last MOLLY update from the hospital.
It has taken vet Amy a little while to figure out but she got there in the end, that Molly takes being moved and buggered about with extremely badly, becomes nervous and withdrawn and goes on hunger strike every time.
This is the first I've heard that she lost around 3-400 grams with her move from Hot cat to Cool cat ward so they decided to "let her eat whatever she wants" over the weekend. I bet they didn't think to offer strawberry ice cream or lemon cheesecake. 350 grams would be like a 12 and a half stone (80kg) person losing nearly one stone (6.2kg) in 3 days.

She was absolutely fine even with that drastic weight loss, in her case because she didn't settle.

[booktigger]

I haven't got any RI experience, but just on the hospitalisation/weight loss, Lucy lost nearly 500g after her hip operation, as she's another one that doesn't do well being hospitalised (the second time, I had to do a 25 mile round trip every day to get her to eat!) and she was also fine after

[Mollycat]

You are aware that Mirtazipine is an antidepressant? I see one side effect is weight gain and increased appetite but also nausea and anxiety, I take it this has all been discussed and reviewed and it's definitely the teeth preventing her from eating?

[fjm]

Pippin went in on the 27th March, and moved from close confinement to the more open side on 5th April, so on the 6th day. Too long for a cat to go without eating...

[MissMidwinter]

You are aware that Mirtazipine is an antidepressant? I see one side effect is weight gain and increased appetite but also nausea and anxiety, I take it this has all been discussed and reviewed and it's definitely the teeth preventing her from eating?

Good thinking. I very reluctantly allowed her to have Mirtazepine - and only half a tablet, as needed, as the combination of a whole tablet with hyperthyroid hunger was just too much - when she had completely stopped eating and drinking and her weight had dropped below 3kg. She was very ill at this point. She seems to do well on it and it can apparently last up to 3 days in cats, so at the moment she has a half tablet every 2-3 days. I'm hoping that at some point in her recovery from the liver problem, that hyperthyroid hunger might take over and she might manage on her own, but at the moment I suspect the dodgy tooth because she does want to eat - is keen enough to take food from the syringe (but only on the left side, avoiding the tooth) - and will try to take food from her bowl, but then turns away. Vet's observation was that if she's happy to eat from syringe, she's probably not nauseous now.

All of this is making her sound like a weak, debilitated old lady - which she's not, at all!

[MissMidwinter]

I haven't got any RI experience, but just on the hospitalisation/weight loss, Lucy lost nearly 500g after her hip operation, as she's another one that doesn't do well being hospitalised (the second time, I had to do a 25 mile round trip every day to get her to eat!) and she was also fine after

Yeah, I think probably lots of cats don't do well in hospital, and under normal circumstances the vets probably expect that and are ready to deal with it. But Chessie is under 3kg now, with a fair bit of it being muscle loss from the hyperthyroid. Also of course, if they don't eat for more than a couple of days they're at risk of very serious liver complications, so a 4-14 day isolation period is quite a worry ...

[MissMidwinter]

Pippin went in on the 27th March, and moved from close confinement to the more open side on 5th April, so on the 6th day. Too long for a cat to go without eating...

Yes. We are considering the Wetherby centre because they *say* cats are sometimes out after 4 days ... after which we could deal with the non-eating at home I think. But 4 days probably isn't the norm, whatever they say.