Please note: We are not veterinarians and this does not constitute medical advice. If there is a change in your cat's eating habits, it is always wise to seek medical advice and obtain proper diagnostics.
Cats are not "just pukers." Cats should not be sensitive to animal proteins, and they should not be tossing hairballs with any frequency. In some cases, the reputation of our “picky” eaters is merited: but for many, that pickiness we observe is actually a communication and the first indication that something isn’t right. Often the problem is the food they are eating.
In Part 1 of this series, we discussed how long term use of antacids may raise stomach pH, which in turn can cause a number of health problems. In Part 2, "Managing Nausea: The Role of Food," we talked about how to identify nausea in your cat (including subtle symptoms), hairballs, and how food is a primary source of tummy (and other gastrointestinal) troubles in our cats.
As the primary cause of nausea and vomiting in our cats is food related, often managing nausea and/or vomiting in your cat is as simple as finding a non-kibble, meat-based, grain-free, low carbohydrate food that agrees with your kitty. Sometimes this doesn’t seem so simple as your vet or other cat parents offer suggestion after suggestion and your “picky” kitty turns up her nose at food after food. But the short-term use of a bland diet makes food-related identification simple and straightforward. This frequently resolves the problem if there isn’t an underlying disease. A bland diet doesn’t identify the problem ingredient(s), but if the food your cat has been eating is the source of the problem, a bland diet will identify that. At that point, controlling the ingredients with balanced homemade fresh food is easy, whether cooked or raw. Commercial fresh food (raw) products are becoming more widely available, and often a species-appropriate, less processed food resolves the problem – such as a food made with EZcomplete fur Cats. If it is a protein sensitivity, a single-protein fresh food diet will identify the allergy. Hopefully you are able to identify at least several proteins to include in rotation to prevent a new sensitivity from developing.
If the bland diet resolves the problem, great! We know how to proceed. If not, until - and if - we can identify the source of the nausea to treat it, or if kitty has a condition that requires ongoing nausea management, there are healthy alternatives to Pepcid a/c (famotidine) or Zantac (ranitidine) that may resolve the nausea without the potential long term use side-effects. If famotidine or ranitidine are needed, use them. But if you want to seek alternatives, these include:
For Immediate Relief
Slippery elm bark powder
Distilled or organic aloe vera juice (made from the inner leaf gel only)
Longer Term Management
Any or all of these can be used together. In fact, probiotics, slippery elm bark powder, and the aloe vera juice (that contains no latex) work together synergistically.
Prescription Alternatives to antacids: Anti-emetic (central nausea) medications
We note that many cats are prescribed reglan (metoclopramide). This medicine increases muscle contractions in the upper digestive tract and triggers gastric emptying. This drug can be an important short term tool, but it can cause serotonin syndrome and/or extreme anxiety and restlessness in some cats. Longer term use can cause an irreversible movement disorder.
Management of Nausea in Chronic Kidney Disease
For cats in chemotherapy or with chronic kidney disease (CKD), medical management may be necessary. Nausea in CKD is often ascribed to acid overproduction, but a study published in 2014 found this not to be the case. Cats, unlike dogs and humans, appear to suffer from central nausea, not gastritis related to acid overproduction. The study found “gastrointestinal signs noted in CKD cats may be more the result of uremic toxins and centrally acting emtogens than due to pathology within the stomach. The more common administration of antacids and gastroprotectants in cats may not be justified. … Management of gastrointestinal signs by use of anti-emetic and anti-nausea drugs may be more worthwhile in cats with CKD.”
The two most commonly prescribed antiemetic drugs that treat central nausea in cats are Cerenia (maropitant) and Zofran (ondansetron). If one doesn’t work, try the other. But notably, Cerenia is processed entirely by the liver with no kidney involvement. Also, any of the alternative nausea treatments discussed here can safely be used in kitties with CKD. Fluids and B12 are likely already a part of their treatment plan.
Alternatives for Management of Nausea
Slippery Elm Bark Powder
Slippery elm bark powder (SEB) is safe and non-toxic for cats. It may interfere with metabolism of medicine, so please give any meds at least 2 hours before or after giving slippery elm bark powder to your kitty.
Often SEB is all that’s needed to settle an upset stomach. As Dr. Hofve says, “It can be thought of as a sort of natural “Pepto-Bismol.” (Pepto-Bismol itself should not be used because it contains salicylate, a.k.a. aspirin). Its mucilage content coats, soothes, and lubricates the mucus membranes lining the digestive tract. Slippery Elm is an excellent treatment for ulcers, gastritis, colitis, and other inflammatory bowel problems. It is high in fiber, and so helps normalize intestinal action; it can be used to relieve both diarrhea and constipation. It may also help alleviate nausea and vomiting in pets suffering from non-GI illnesses, such as kidney disease.”
It is best if purchased as loose powder rather than in capsule form, as flow agents are required in the product when encapsulated. For nausea, it works best as a kind of “gruel” (gel) or “syrup” and given one-half hour to 45 minutes prior to a meal. Given kitty is nauseous and inappetent, you will most likely have to syringe it if made into a syrup, or spoon or finger feed it if used as a gel or “gruel.”
For the quick thick gel, mix one-quarter teaspoon of the powder with one-half teaspoon of water. Let it thicken. You may need to add water to get it into the syringe, that’s OK. Give 3 – 5ML (CC).
For the “syrup,” mix 1 teaspoon of SEB powder with one cup water. On the stove: bring to a boil, then let simmer for three to four minutes, whisking basically constantly. It will thicken as it cools. In the microwave: heat on high 30 seconds, stir. Repeat. Then cook it at 50% power for four minutes, stopping it every 20 to 30 seconds to stir so it doesn’t boil over. This can be refrigerated for up to 5 days, just take it out to use as needed.
For more information on slippery elm bark powder, please see:
Slippery Elm http://www.littlebigcat.com/health/slippery-elm/
The Numerous Healing Properties of Slippery Elm http://www.promedics.ca/site/downloads/Slippery%20Elm.pdf
Aloe Vera Juice (Distilled or from inner leaf only, do not use juice that may contain latex from the leaf)
Aloe vera is well known for nutrient compounds that help heal and soothe the skin when used externally; it has similar benefits on the lining of the digestive tract when taken internally. Aloe decreases irritation and enhances healing and repair of ulcers in the stomach and intestines; it helps reduce intestinal inflammation. It can neutralize excess stomach acid without the pH rise associated with antacids over time, and it acts as a prebiotic, helping to promote the growth of healthy bacteria that aid digestion.
Up to twice a day, distilled aloe vera juice can be used in place of water to make the slippery elm bark gel or “gruel.”
If not using SEB powder, one-half teaspoon of aloe vera juice can be given to kitty to drink or administered plain, via syringe, prior to a meal twice a day. It can also be mixed into food: this promotes healing longer term, but it doesn’t provide nausea relief if kitty isn’t eating.
Longer term, combining SEB powder, aloe vera juice, and an L acidophilus-based probiotic is an anti-inflammatory therapy that aids gastrointestinal health. To use this, mix one part SEB powder to 2 parts aloe juice (1/4 teaspoon SEB powder and 1/2 teaspoon aloe vera juice). Let it gel. Add and mix in the probiotic of choice. This can be given twice a day, and this can be added to food (if kitty is eating).
In the U.S. we suggest George’s or Lily of the Desert organic preservative-free unflavored juice. The organic is a bit bitter and kitty may not like it; the George’s has no taste but is not organic.
For more on Aloe Vera Juice, please see
Aloe Vera and Probiotics: A New Alternative to Functional Foods, Cuvas-Limón et al 2015. Annual Research & Review in Biology, 9(2): 1-11, 2016, Article no .ARRB.22622
Aloe vera and GI Tract Health https://www.lorandlabs.com/pdf/Aloe%20Insight%20-%20Aloe%20vera%20and%20GI%20Tract%20Health.pdf
Health Risks & Benefits of Taking Aloe Vera Juice Internally http://healthyeating.sfgate.com/health-risks-benefits-taking-aloe-vera-juice-internally-5017.html
Aloe Vera Gel Research Review http://naturalmedicinejournal.com/journal/2012-09/aloe-vera-gel-research-review
Acupuncture for Nausea
To date, more than three dozen randomized controlled studies have been published showing that acupuncture point stimulation can treat or prevent nausea and vomiting. If you are in the U.S., you can search http://www.ahvma.org to see if there is a vet trained in acupuncture near you. I also recommend using an internet search to look for “holistic vets,” “Integrative vet,” “acupuncture vet,” etc. in combination with the name of your town, county, or nearby large city (if there is one). For the scientific-minded, this study (originally published in Hebrew) discusses how acupuncture works in managing nausea. How often your cat would benefit from the treatments will be discussed with the vet. But acupuncture in cats has proven to be very effective at helping treat nausea and usually results in an increased appetite.
Chronic vomiting or diarrhea, or a bout of vomiting or diarrhea can cause dehydration. Even subtle, mild dehydration can make your cat feel worse and exacerbate nausea. Sometimes fluid administration helps tremendously. This is obviously true for CKD cats who run the risk of dehydration due to improperly functioning kidneys and frequent urination. This may also help diabetic cats and cats with hyperthyroidism while you work to find the correct doses of medication to manage the diseases. Talk to your vet about administering sub-q fluids at home. If it is deemed safe and appropriate for your cat’s circumstances, having fluids on hand can make a real difference in how your kitty feels.
If you do not have sub-q fluids on hand, you can offer “tuna water” (drained from a tin of tuna); or slowly syringe plain water or coconut water (make sure it is unflavored with no preservatives). Coconut water is very similar in make-up to oral rehydration solutions, it contains properly balanced electrolytes naturally - but it does contain sugars. The use of children’s unflavored pedialyte is controversial due to the dextrose (sugar). Plenty of vets suggest it; others feel strongly the sugar is inappropriate for our obligate carnivores. But if your cat has been vomiting and is dehydrated and you don’t have sub-q fluids on hand, a homemade oral rehydration solution can get your kitty through the night and to the vet the next morning.
Oral rehydration solution: I make it by boiling, then cooling, one cup of water, and adding a small pinch of baking soda, a small pinch of salt, and a teaspoon of raw, organic honey. You can use a teaspoon of table sugar instead of the raw honey (do NOT use honey if it is not raw, the regular sugar is better). If the use of sugar, diluted, in such small amounts for a short period of time makes you uncomfortable, just syringe plain water and call the vet ASAP. But if you have a diabetic cat and your kitty is vomiting to the point of dehydration, if you can’t get to an emergency vet, that little bit of sugar may be a life-saver.
For GI diseases that involve inflammation and malabsorption (such as inflammatory bowel disease, exocrine pancreatic insufficiency, pancreatitis, or intestinal lymphoma) or increased thirst and thus urination (such as hyperthyroidism, diabetes, or chronic kidney disease), B12 shots should be considered essential, in my opinion. Like fluids, vitamin B12 supplementation greatly enhances kitty’s well-being. B12 is water soluble, so even if B12 levels are not found to be low in blood work, your cat may benefit. It will not harm your cat to try, so ask your vet! Discussed at length here, with discussion of dosages here, you’ll note that a wonderful side-benefit of B12 is an increased appetite.
Recent research has made it clear that we depend on our healthy bacteria for our health. In fact, our bacterial balance is so important to our immune system and digestive function, it can almost be thought of as another organ. A report published in September of this year put it this way “It is comparable to the immune system in as much as it is made up of a collection of cells, it contains a 100 times more genes than the host, is host-specific, contains heritable components, can be modified by diet, surgery or antibiotics, and in its absence nearly all aspects of host physiology are affected.”
Probiotics help us and our cats metabolize nutrients from our food, prevent the overgrowth of unhealthy bacteria, support almost every aspect of our immune system, regulate our moods, our weight, resolve and prevent allergies, regulate inflammation, and appear to help protect against several gastrointestinal-related cancers.
In the wild, a cat essentially gets a dose of probiotics with every meal. By eating the guts of its prey, kitty has a constant supply of bacteria to “feed” its gastrointestinal tract, its “microbiome.” The diet we feed our cats, even those feeding fresh food, is devoid of probiotics unless we supplement them.
Unfortunately, only limited data is available about the bacterial profile of cats. A May 2015 study of the fecal microbiome in cats with diarrhea was compared to healthy cats and significant differences were found: gut dysbiosis (the balance of GI bacteria) plays a very real role in the proper function of our cats’ GI system. Many recommend using “species-specific” strains of bacteria, as our cats do have bacteria that are unique to them. Ideally, we would provide bacteria derived from cats for best results. But so little is known about cat-specific species, one of the lead researchers in the field feels that probiotic selection for use in pets should be based on researched strains, not whether or not the probiotics are pet-specific, and indicates “studies have shown that human or dairy developed probiotic strains are capable of conferring health benefit across species. At this point there is no proven benefit of using a canine or feline specific strain.”
Probiotics will not resolve nausea or vomiting in your kitty on a “per dose” basis. They are a supplement that works over time, usually not right away. Human brands of probiotics and typical doses for cats are discussed in “Probiotics for Cats: Why, Which Ones, and How to Use Them.”
According to Dr. Jean Hofve, “Digestive enzymes help our pets to fully break down foods so nutrients can be efficiently absorbed and used by the body. When food is not properly digested, some particles may trigger inflammation, allergies, and other chronic health problems. Processed foods have had their native enzymes destroyed, so it is important to add them to your pet’s food. Plant- or fungal-based enzymes work in the widest range of pH and temperature. Make sure that the product you select contains at least protease, amylase, lipase, and cellulase.” Fat malabsorption is a common problem for cats with brewing GI issues. This is often a cause of gas, discomfort, and stinky stool (usually in the form of diarrhea). Kitty should be taken to the vet for blood work to rule out Exocrine Pancreatic Insufficiency (EPI). But in the absence of EPI, digestive enzymes can greatly benefit kitty’s GI health, comfort, and nutrient absorption.
For more information, please see
Digestive Enzymes http://ivcjournal.com/digestive-enzymes/
Digestive problems are so widespread in cats, according to VPI Insurance, they have ranked as one of the top two reasons for a vet visit seven out of the last nine years. Nausea and inappetence – “pickiness” in our cats – is not something to be taken lightly. One retrospective study of 300 cats with a history of chronic vomiting, weight loss, chronic diarrhea or a combination of those, found that 288 – 96% !!! – of those cats had either cancer or inflammatory bowel disease. Plenty of jokes abound about what we perceive as our haughty feline companions, or we write off our kitty’s problem as “just” hairballs or “he’s just a puker.” Cats should not be puking, they should not be sensitive to animal proteins, and they should not be tossing hairballs with any frequency.
In some cases, the reputation of our “picky” eaters is merited: but for many, that pickiness we observe is actually a communication and the first indication that something isn’t right. Picky kitties are often actually at least slightly nauseous kitties. Clearly the first step is a visit to the vet. But if no underlying disease or cause is found, please remember as discussed in Part 2, the food we feed is often the culprit. If food changes as outlined don’t help, or if there is underlying disease that requires management of nausea, we hope these nausea management approaches help minimize the need for the use of antacids. Antacids are an important tool in the medicine chest, but it is best for kitty’s long term health to use them sparingly if possible.
Eamlamnam et al 2006. Effects of Aloe vera and sucralfate on gastric microcirculatory changes, cytokine levels and gastric ulcer healing in rats, World J Gastroenterol Apr 7; 12(13):2034-9 (2006). http://www.ncbi.nlm.nih.gov/pubmed/16610053
Hofve, Jean DVM. Digestive Enzymes, IVC Journal; Spring 2012. http://ivcjournal.com/digestive-enzymes/
Humphries C. 2015. The Deep Symbiosis between Bacteria and Their Human Hosts is Forcing Scientists to As Are We Organisms or Living Ecosystems? Seedmagazine.com October 11, 2015. http://seedmagazine.com/content/article/the_body_politic/
Kumar et al 2010. Cancer-preventing attributes of probiotics: an update, Int J Food Sci Nutr Aug; 61(5):473-96 2010. http://www.ncbi.nlm.nih.gov/pubmed/20187714
Marchesi et al 2015. The gut microbiota and host health: a new clinical frontier, Gut Sep:1-10 2015. http://gut.bmj.com/content/early/2015/09/02/gutjnl-2015-309990.full
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Samuels N. Acupuncture for nausea: how does it work? Harefuah Apr; 142(4):297-300, 316 (2003). http://www.ncbi.nlm.nih.gov/pubmed/12754882
Sierra-Garcia GD et al. 2014. Acemannan, an extracted polysaccharide from Aloe vera: A literature review, Nat Prod Commun Aug; 9(8):1217-21 (2014). http://www.ncbi.nlm.nih.gov/pubmed/25233608
Suchodolski JS. 2011. Companion Animals Symposium: Microbes and gastrointestinal health of dogs and cats, J Anim Sci 89:1520-1530 (2011). https://www.animalsciencepublications.org/publications/jas/pdfs/89/5/1520?search-result=1
Suchodolski JS. 2014. The Use of Probiotics in Small Animal Medicine, Polish Veterinary Journal transcript. https://assets.documentcloud.org/documents/1875880/probiotics-polish-vet-journal-suchodolski-final.pdf
Suchodolski et al 2015. The Fecal Microbiome in Cats with Diarrhea, PLoS ONE 10(5): e0127378 May 2015. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0127378
Wynn, SG 2009. Probiotics in veterinary practice, JAVMA 234(5):606-613 (2009). http://www.winnfelinefoundation.org/education/cat-health-news-blog/details/cat-health-news-from-the-winn-feline-foundation/2009/04/02/probiotics-for-cats