Pilling Cats (and Dogs) and Erosive Esophagitis

Compounded Flavored Liquid Alternatives

Transdermal Medications

Lisa A. Pierson, DVM

Think about the last time you swallowed a pill or a capsule.  You most likely took it with several swallows of something liquid to help move the pill along its journey through the esophagus and into the stomach.  Most people would never dream of 'dry swallowing' pills, having felt that awful sensation of a pill not 'going down' very smoothly so why are we subjecting our animals to this illogical procedure?  When humans feel that a pill is 'stuck', we usually react by drinking more water.  It would be nice if cats and dogs reacted this way, but they don't.

Here is a quote from a colleague of mine:

"Last year, I was prescribed clindamycin (Antirobe) for a dental infection and was instructed to take each capsule with a full glass of water.  One night, being lazy, I took the capsule with just a gulp of water.  What ensued was the worst case of heartburn/esophagitis I have ever had.  At first, the pain was so intense I thought I was having a heart attack.  This cured me of ever pilling a cat without a water or food chaser."

For this article, a "dry swallow" refers to the administration of a pill or capsule to a cat or dog without immediately following up with several milliliters (cc's) of water, or tuna juice or meat broth given orally via a syringe, or the consumption of some canned food by the patient.  Offering tuna juice, meat baby food, or a meat broth for them to lap up on their own are also very good options and ones that are less stressful than syringing.

As an alternative to pilling, I strongly urge people to have their cat's medication made up into a flavored liquid compound for ease of administration.  That said, some people state that their cat is not good about swallowing liquids and these people prefer to use pills.

A third option is to use Pill Pockets.  If your cat will eat these treats, they will provide a stress-free way of administering medications especially if your cat still has a good appetite and the pill is not too large or bitter. 

When administering pills or capsules, some people use butter or oil to coat the pill/capsule.  This will make swallowing the pill easier, but it is also very important to follow a butter-coated pill with a liquid or food chaser to ensure that the pills or capsules move immediately into the stomach.

If a cat absolutely will not allow water to be syringed after pilling, or he will not eat or drink afterward, then you can put some butter or a product like Nutrical on his paw.  The licking of the butter/Nutrical from the paw (or even the nose) has been shown to hasten the travel of the pill into the stomach.

The best size of syringe to use for a cat - whether you are syringing the medicine or a water chaser - is a 1 cc ("TB") syringe.  The larger syringes do not fit comfortably inside of a cat's mouth.  Also, you do not want to administer any more than 1 cc at a time.  If liquid medications, such as some of the commonly used antibiotics, are dispensed with an eyedropper, ask your veterinarian for a 1cc syringe.  Not only is this a more accurate way to measure the dose, but your cat will be more agreeable to this small syringe entering the side of his mouth rather than the larger eyedropper that you have to squeeze a couple of times to eject the medication.

If you have chosen the option to pill your cat, I would suggest that before you get ready to administer the pill, have a bowl of water (or tuna juice or broth) readily available.  See if your cat is interested in drinking it.  If not, you will then have to use your syringe.  To administer a liquid using a syringe, it is best to approach the cat from the side, not from the front.  Cats tend to be a bit worried when approached head on.  Slip the syringe into the side of the mouth at about a 45-degree angle being careful not to insert the syringe too far down the back of the throat.  You don't want the cat to panic, nor have him aspirate the liquid.  Do not hold your pet's head up!  This is something that I commonly see people do.  Try it yourself.  Lift your chin up and you will see how much harder it is for you to swallow.  You can hold his head level or his mouth slightly down, but never raise his head upward.

Believe me when I say I fully understand that some of the readers will be saying "oh sure...I can barely get the pill down my cat and now I am supposed to follow up with the syringing of some liquid?!!?"  I realize that none of this will be easy with some cats, but my goal is to get people to start thinking about this issue and not take the dry pilling of an animal lightly.  For those hard-to-pill cats, please see below for other alternatives such as compounded, flavored liquid medications and transdermal preparations.

Another option is to see if the cat or dog will consume the pill if it is hidden in canned food.  This is obviously the least stressful for all concerned but it usually works better with dogs.  Cats are notoriously picky eaters and are suspicious of anything out of the ordinary in their food.    Some drugs such as Clavamox tablets and Baytril TasteTabs are formulated to be fairly palatable and can be crushed and put in the food and this is a great way to go....if the cat will eat it.  I have had better luck with cats eating crushed Clavamox tablets in food than I have with the Baytril TasteTabs.  

Note:  When I use the word "pill", I am also referring to capsules which can cause even more problems than pills, as shown in the study below. 

Given the facts regarding how humans take their medications and vitamins,  why do we ask our cats and dogs to do something we would never do?  Why do we ask them to dry swallow a pill which quite often ends up lodged in the esophagus with the real potential to cause a very painful condition called erosive esophagitis?

The lining of the esophagus is very delicate and it is not designed to have irritating medications in contact with it for more than the short amount of time it should take for the pill to pass from the mouth to the stomach when swallowed with an adequate amount of liquid or food.  When a pill is in contact with this tissue for a prolonged period of time, a painful irritation or ulcer has the potential to develop.  Some medications are worse than others.  For instance, doxycycline is a well-known antibiotic that is extremely irritating.  (More on that below from a human who experienced very painful erosive esophagitis from taking this medication without enough water.)

Please note the following case study where another antibiotic, clindamycin (Antirobe), also resulted in severe injury to the patients:

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Suspected clindamycin-associated oesophageal injury in cats: five cases

Journal of Feline Medicine & Surgery, Volume 8, Issue 6, December 2006, Pages 412-419
Julia A. Beatty BSc(hons), BVetMed, PhD, FACVSc (Feline Medicine), MRCVS, Nigel Swift BVetMed, Dip ACVIM (Small Animal Internal Medicine), MRCVS, Darren J. Foster BSc, BVMS, PhD, FACVSc (Feline Medicine) and Vanessa R.D. Barrs BVSc(hons), MVetClinStud, FACVSc (Feline Medicine)

Accepted 24 April 2006.  Available online 18 July 2006.

Summary

The clinical findings, treatment and outcome of suspected clindamycin-associated oesophageal injury in five cats are reported. All cats were treated with one 75 mg clindamycin capsule twice daily (dose range 12–19 mg/kg). Capsules were administered without food or a water bolus. Dysphagia, regurgitation, choking or gagging were seen 3–9 days after starting clindamycin. On oesophagoscopy, three cats had oesophagitis, one of which progressed to stricture formation. Two cats had an oesophageal stricture at first presentation. This is the first report of suspected clindamycin-associated oesophageal injury in cats. It serves to further alert practitioners to the potential for drug-induced oesophageal disorders (DIOD) in cats treated with oral medications and to urge prevention by promoting a change in dosing practices.
End abstract.

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Please note this excerpt from the study quoted below:

"After 5 minutes 84% of capsules and 64% of tablets are still sitting in the esophagus."  This is referring to pills and capsules that were dry swallowed.

It really is amazing that cats and dogs are as good as they are about pilling but one has to wonder about the pets that panic and/or gag when their owners try to pill them.  I know that I would not be very happy about being asked to dry swallow a pill.

A Very Interesting Study

The following is a summary of a very interesting article that appeared in a veterinary journal entitled Evaluation of the Passage of Tablets and Capsules Through the Esophagus of the Cat. It is from a paper presented at the 2001 American College of Veterinary Internal Medicine Forum. (They do note at the end of the paper that the principles outlined also make good sense for dogs.)  This paper was submitted to one of the lesser-read journals so a lot of veterinarians may not have seen it.  This is extremely unfortunate for all cats and dogs.

Purpose of the study:
The goal of the study was to determine the length of time that it took for pills or capsules to enter the stomach after 1) dry pilling and 2) pilling and then giving a 6 cc water chaser immediately following the administration of the pill or capsule - referred to as a "wet swallow".

Study design:
30 cats were used. Fluoroscopy was used to evaluate the pill/capsule passage at 30, 60, 90, 120, 180, 300 seconds.

Study results:
For the dry swallows:
No pills were in the stomach at 30 and 60 seconds.  Only 6% of the pills were in the stomach at 90 seconds. Only 13% of the pills were in the stomach at 120 seconds. And at 5 minutes only 36% of the pills were in the stomach.

For the wet swallows: (i.e., the pill was followed by 6 cc of water)
At 30 seconds, 90% of the pills were in the stomach. All pills were in the stomach by 120 seconds.

The statistics were even worse for capsules when dry swallowed.  By 5 minutes, only 16% of the capsules had made it to the stomach. 100% of capsules followed by water chasers, were in the stomach by 60 seconds - faster than for pills probably due to the smoother surface of a capsule versus a pill.

Commentary:
"This is an interesting study that has considerable practical impact.  Although veterinarians have a huge arsenal of mediations and treatments available to us, we still have a very poor understanding of some of the most basic aspects of everyday practice. We routinely prescribe oral medications in the form of tablets or capsules to cats.

It has been our assumption that when it was possible for the owner to actually give the pills or capsule to the cat, it would make it into the stomach reasonably rapidly. It turns out that this is inaccurate. After 5 minutes 84% of capsules and 64% of tablets are still sitting in the esophagus. Similar results were published in another study by JP Graham (American Journal of Veterinary Research 2000).

Practical outcome:
The main concern with this information is that if tablets and capsules sit in the esophagus for a prolonged period of time, this can cause damage to the tissues in this area. This damage can lead to esophagitis, which can lead to nausea, vomiting and megaesophagus. At times, the esophagus can also respond by developing an ulcer or stricture. The latter is a very serious complication requiring aggressive therapy, preferably with balloon dilatation.

In addition, we probably have all had that uncomfortable feeling when a tablet we have taken has gotten stuck on the way down. This could be the cause of vomiting in some cats that are medicated. It is quite frustrating to win the battle to get the pill or capsule down a cat and then have it vomited up several minutes later.

Both this abstract as well as the study published by Graham et al. clearly point to the need to administer either water or food after a cat has been pilled with a tablet or a capsule. This will hasten the movement into the stomach and cut down on the chances of the tablet or capsule remaining in the esophagus for a prolonged period of time. Although comparable studies have not been done in dogs, this advice is sound in dogs, as well."
(End of quoted study)

The following is an anecdotal report from a person who ended up with a very painful case of an ulcerated esophagus after a capsule became lodged in her esophagus:

"I know the pain of an ulcerated esophagus personally and it is a living hell.  I was on doxycycline capsules (due to a cat bite) last year and one got stuck in my esophagus.  I did not think it was a big deal and went to bed figuring it would eventually work it's way down. Several days later I had suffered so much that I took myself to the ER.  I had to drink this horrible tasting cocktail with liquid lidocaine to get relief. It worked, temporarily, but I had to drink a tsp of the lidocaine 3x a day just to be able to swallow for about 30 minutes each time.  Forget eating.  I lost 10+ lbs in less than 2 weeks. I couldn't eat at all and could not swallow without the lidocaine.  I laid in the bed with a cup to spit in because it was too painful to swallow.  It was a great diet, but not one I'd recommend.  Please take every precaution you can to make sure this does not happen to your pet."

Compounded Flavored Liquid Medications

 

As an alternative to using pills and capsules to administer medications, certain pharmacies can compound the medications into flavored liquids.  Please be aware that compounded medications may be more expensive than medications dispensed by your veterinarian, but the use of these liquid medications can alleviate a great deal of stress for both the pet and the human.  I am very involved in rescue work and often deal with extremely frightened and painful animals whose trust I am trying to gain.  Pilling a sick cat/kitten who is feral or traumatized/frightened/painful, or has severe upper respiratory disease and can hardly breathe as it is, does not exactly make for a fast friendship and development of trust.

When an animal is ill or injured, the last thing we want to do is add more stress to the situation.   I adopted a 9 year old cat out to a really nice woman 4 years ago. She recently called me in tears because Caliban was now in congestive heart failure and she was having a hard time pilling him and was going to put him to sleep since he could no longer receive his necessary medications. She felt so guilty for failing Caliban by not giving him the medications that he desperately needed but was also feeling guilty for stressing the heck out of him in his final days with the pilling. This stress was alleviated by using compounded, flavored liquid medications.

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The most common flavor used for cats is 'triple fish' and if dealing with a very bitter medication, this flavor is the best one to use.  Another flavor that is used is chicken and some cats do better with this milder flavor than the very strong triple fish.  

Please note that some drugs are so bitter that even compounding will not hide the awful taste.  An example of this type of drug is amitriptyline which is often used for anxiety and inappropriate elimination problems.  Fortunately, this medication is formulated into a small, coated pill but a food or liquid chaser still needs to be administered if the cat is pilled.  Or, because this pill is small and coated, another option is to hide it in canned food.

Since we all know that every cat is different, I will mention again that some people state that they have had much better luck pilling their cats than trying to get liquids into them.  Some cats throw a fit if given liquid medications.  The problem with these cats, however, is that if you do pill them successfully, they are not apt to take the water chaser very well.  This presents a bit of a problem and the hope is that they will eat some canned food or drink some tuna juice or meat broth after being pilled.

Another favorable aspect of using a compounding pharmacy is that you can pick the drug concentration so that the necessary dosage volume is not over 1cc.  I try to have the medication mixed in a concentration that enables me to give 1/2 - 3/4 of a cc or 1cc at the most. This is an easy volume to administer to a cat.

Occasionally you may run across a drug that can't be compounded but I have yet to run into this situation.  
 

Transdermal Medications
 

Transdermal preparations are medications that are formulated into a gel or ointment that can be applied to the inner ear of the cat.  After application, the medicine is then absorbed through the skin.  Unfortunately, not all medications do cross through the skin barrier so please discuss this issue with your vet and pharmacist for each individual medication considered.  Some medications cannot be compounded into transdermal preparations or are not absorbed properly to ensure an adequate blood level.  Baytril is one drug that does not achieve adequate blood levels and should not be used in a transdermal preparation.

One medication that is often used with this route of administration is methimazole (Tapazole) which is a commonly prescribed hyperthyroid medication.  Studies here and here have shown that the use of transdermal methimazole is a very effective way to administer this drug and results in fewer gastrointestinal upsets.

Another medication that has been formulated into a transdermal preparation is amitriptyline but I do not know of any studies showing the efficacy of this route of administration for this particular drug.

Conclusion 

The goal of this article is to prevent the silent suffering that our pets often go through when medications are administered without appropriate precautions.  I have outlined several options above:

1) Administer the pill or capsule and follow up immediately with a chaser of a liquid

using a syringe.

6) Or...be lucky enough to have your cat eat the medication in canned food.

Please pass this information on to anyone whose pets may benefit from the information.  It is my hope that the information will help to save some of our non-speaking friends from a painful esophagitis and their caretakers from the stress of pilling some hard-to-pill cats.