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Liver disease is the catch-all term that is applied to any medical disorder affecting the liver and usually causing elevated blood levels of liver enzymes. It can be divided into both acute and chronic disease. Causes of acute liver disease include toxins (a number of drugs have been implicated in causing acute liver disease, including Tylenol, Rimadyl, Valium, tetracycline, sulfa drugs, and mushroom poisoning); also, hepatic lipidosis, trauma, heatstroke, and infections (canine infectious hepatitis). Causes of chronic liver disease include genetics, infections, toxins (anticonvulsants, Rimadyl), and idiopathic hepatitis.

Feline cholangiohepatitis is a common inflammatory liver disease in cats that may be associated with infection of bacteria from the intestines that ascend the bile ducts.

Certain breeds of dogs are prone to chronic hepatitis and cirrhosis (an end stage of liver disease in which liver tissue is replaced with fibrous tissue). Doberman Pinschers (especially females), American and English Cocker Spaniels, Bedlington Terriers, and West Highland White Terriers are the breeds associated with chronic liver disease and cirrhosis.

Clinical signs of liver disease include lack of appetite, vomiting, diarrhea, increased thirst, increased urination, lethargy, jaundice, and seizures. Liver disease is diagnosed by blood and urine tests, abdominal x-rays, and abdominal ultrasound. Liver biopsy is needed to determine the cause of liver disease.

A common liver disease in cats is hepatic lipidosis (fatty liver disease). This occurs in cats (and sometimes in dogs) as a result of starvation and weight loss (hepatic lipidosis can occur in cats who do not eat for as little as 72 hours). Depletion of certain nutrients (choline, carnitine, arginine) impairs metabolism of fat, resulting in fat deposition (rather than removal) from the liver.

PRINCIPAL NATURAL TREATMENTS FOR LIVER DISEASE IN PETS

Natural Diet—Dietary therapy is a mainstay of treating the pet with liver disease, as there are few conventional medications that actually treat liver disease. High quality and highly digestible carbohydrates are recommended to supply energy for the pet. Inferior types of carbs that are undigested are fermented by intestinal bacteria, which increase the bacteria in the colon. These bacteria then break down dietary proteins and produce extra ammonia, which is absorbed into the body and contributes to toxicity in pets with liver disease. Frequent feedings of high-quality, simple carbohydrates such as white rice and potatoes are recommended. Vegetables act as a source of complex carbohydrates and provide fiber; the fiber helps bind intestinal toxins and promotes bowel movements to remove these toxins (by-products of protein digestion and bacterial fermentation of undigested foods) from the body.

Proteins provided by the diet must be of high biological value to reduce the production of ammonia, a by-product of protein digestion. Most commercial foods contain proteins that are not of high biological value. (Many commercial foods may also contain excess vitamin A, copper, and bacterial endotoxins, all of which contribute to the clinical signs in pets with liver disease.) Unless your doctor recommends protein restriction (usually only needed by pets with encephalopathy, a condition producing neurological signs in pets with sever liver disease), normal amounts of protein should be fed, as the liver needs protein during repair.

Studies show that dogs with liver disease fed diets containing meat-based proteins have shorter survival times and more severe clinical signs than dogs with liver disease fed milk-based or soy-based protein diets. Cats require higher protein diets than dogs. While it may be more beneficial to cats to also feed them diets based on milk-based or soy-based proteins, most cats prefer meat-based diets. Cats fed milk-based or soy-based proteins must have supplemental taurine (100–200 mg/day), as milk has minimal taurine and soy has no taurine.

In cats, hepatic lipidosis is the most common liver disease and is secondary to starvation (often seen in overweight cats who go without eating for as little as three to five days). It is a secondary complication of anorexia and obesity rather than a true primary liver disease. Force-feeding cats to help heal the liver and correct the underlying problem is the treatment to hepatic lipidosis. This often requires tube feeding of special diets. When feasible, high-fat (approx. 30%) enteral diets containing milk-based or soy-based proteins are ideal for these cats; taurine supplementation of 150 mg/8 ounces of liquid diet is recommended.

Adding the amino acids arginine or citrulline to the diet may be indicated, as these amino acids accelerate the conversion of highly toxic ammonia to urea, reversing the clinical signs of toxicity that may occur in pets with liver disease. Glycine may decrease the toxicity that affects the kidneys when the chemotherapy drug cisplatin is administered.

Fat is used in the diet for energy. Even pets with fatty liver disease do well on diets containing 20 to 25 percent fat. Free fatty acids contribute to increased blood ammonia by interfering with ammonia metabolism. Dietary fats do not contribute to increased blood levels of free fatty acids; fasting or starvation will contribute to increased levels of free fatty acids. Therefore, pets with liver disease should have diets containing adequate amounts of fats and should receive frequent small feedings. Additionally, small frequent feedings reduce protein breakdown by the body (which can worsen clinical signs), improve glucose metabolism (preventing hypoglycemia), and decrease intestinal ammonia concentrations.

Increasing levels of vitamin A and copper can contribute to liver damage. Zinc supplementation may be of benefit as many pets with liver disease are deficient in zinc, and it can reduce copper absorption. Adding vitamins C, E, and K may be warranted.

Vitamin E protects against metabolism of lipids in cell membranes. Vitamin K is needed for proper blood clotting, which can be a problem in pets with severe liver disease. While dogs and cats can make vitamin C in the liver and do not normally require this vitamin, liver disease may decrease the amount of vitamin C. Supplementation with these vitamins under veterinary supervision may be helpful.

Milk Thistle

Milk thistle is well known for use in liver disease. Its silymarin content has been shown effective in treating liver disease. Milk thistle compounds are usually standardized to 70 to 80 percent silymarin. Milk thistle is one of the few herbs that have no real equivalent in the world of conventional medicine.

The active ingredients appear to be four substances known collectively as silymarin, of which the most potent is named silibinin. When injected intravenously, silibinin is one of the few known antidotes to poisoning by the deathcap mushroom. Animal studies suggest milk thistle extracts can also protect against many other poisonous substances, from toluene to the drug acetaminophen.

Silymarin appears to function by displacing toxins trying to bind to the liver as well as by causing the liver to regenerate more quickly. It may also scavenge free radicals and stabilize liver cell membranes. However, milk thistle is not effective in treating advanced liver cirrhosis, and only the intravenous form can counter mushroom poisoning.

Silymarin protects the liver as an antioxidant, by increasing glutathione levels, and by inhibiting the formation of damaging leukotrienes. Silymarin also stimulates the production of new liver cells, replacing the damaged cells.

Due to its liver support, milk thistle is often used anytime the pet becomes ill to support the liver. It can also be used anytime drugs are given to the pet that could be toxic to the liver, especially chemotherapy medicines, heartworm medications, and long-term use of other medications.

In people, treatment produces a modest improvement in symptoms of chronic liver disease. Liver enzymes as measured by blood tests frequently improve, and if a liver biopsy is performed, there may be improvements on the cellular level. Some studies have shown a reduction in death rate among those with serious liver disease.

A new form of silymarin, in which the compound is bound to phosphatidylcholine, has been shown to have greater bioavailability than unbound silymarin. It is best not to use milk thistle as a daily preventive supplement but rather reserve its use for conditions where the liver is under stress.

The standard dosage of milk thistle is 100 mg per 25 lb of weight, two to three times a day. In people, the best results are seen at higher doses (140 to 200 mg three times daily standardized to contain 70% silymarin); the bound form is dosed at 100 to 200 mg twice daily.

Safety Issues
Do not use milk thistle in pregnant animals. Long-term use may alter blood liver enzymes. High doses may cause diarrhea.

Safety in young children, pregnant or nursing women and individuals with severe renal disease has not been established. Similar precautions in pets are probably warranted.

Other Natural Treatments
Other natural treatments include the nutrients choline, carnitine, and arginine. The herbs boswellia, burdock, chaparral, dandelion root, licorice, nettle, Oregon grape, red clover, turmeric, yellow dock and maitake mushrooms.

Conventional Therapy
There is no specific treatment for liver disease in dogs and cats, unless a specific toxin is identified. Supportive care includes intravenous fluids and force-feeding. Force-feeding is the treatment of choice for cats. It usually requires feeding through a gastrotomy (stomach) tube for two to three months. Antibiotics and/or corticosteroids may be indicated, for example, for feline cholangiohepatitis.

Acupuncture is without a doubt one of the most field-tested techniques available in complementary medicine. For skeptics who question the effectiveness of this popular therapy, a large amount of empirical, as well as experimental, information and studies show the effectiveness of acupuncture.

In its purest sense, acupuncture involves the placement of tiny needles into various parts of a pet’s body. These needles stimulate the acupuncture points, which can affect a resolution of the clinical signs. The points are chosen based on diagnostic tests and or traditional formulas that are known to help pets with specific problems. The points correspond to areas of the body that contain nerves and blood vessels. By stimulating these points, acupuncture causes a combination of pain relief, stimulation of the immune system, and alterations in blood vessels, causing a decrease in clinical signs. Other forms of acupuncture are often chosen to provide the pet more prolonged stimulation, as they produce a higher and more continuous level of stimulation.

They include:
Laser therapy. Acupuncture points may be stimulated by low intensity or cold lasers to promote positive physiologic effects associated with healing and decreased pain and inflammation.

Aquapuncture. Aquapuncture utilizes the injection of tiny amounts of fluid (often vitamins, but also sterile water, antibiotics, herbal extracts, analgesics, local anesthetics, corticosteroids, nonsteroidal medications, or electrolyte solutions) at the acupuncture site for a more prolonged effect.

Implantation. To achieve a more prolonged and intense stimulation of acupuncture points, various objects (usually beads made of gold, silver or stainless steel) are surgically implanted at acupuncture sites.

Electroacupuncture. This form of therapy uses a small amount of non-painful electricity to stimulate the acupuncture site for a more intense effect. Moxibustion. This is the burning of an herb (typically Astesmisia Vulgaris) on or above acupuncture points. The heat from the burning herb gives additional stimulation to the acupuncture points. Care must be taken to avoid burning the pet.

Acupressure. This form involves applying pressure with the fingers to specific acupuncture points. Owners can be taught to apply acupressure at home to the points that have been used during veterinary treatments to augment the acupuncture treatments to give further relief from pain and inflammation.

Most holistic doctors combine acupuncture with other treatments to achieve a truly “holistic” therapy. For example, for pets with osteoarthritis, nutritional supplements that are designed to heal the damaged cartilage are often added to acupuncture treatment, as by itself it will not heal damaged cartilage. Once the pet has improved, doctors will use acupuncture on an “as needed” basis when the pet shows increased stiffness.

Safety Issues
As a rule, acupuncture compares quite favorably with traditional therapies. In some cases, it may be preferred when conventional therapy is ineffective or potentially harmful (such as long-term use of corticosteroids or nonsteroidal anti-inflammatory medication). At other times, acupuncture may be used when an owner cannot afford traditional therapy (such as back surgery for intervertebral disk disease or hip replacement surgery for the pet with severe hip dysplasia). It is ideal if doctors discuss both acupuncture and conventional therapies to allow the owner to make the best decision for the pet.

Side effects are rare. Accidental puncture of an underlying vital organ can occur; this usually happens if the incorrect needle size is placed in an area in which there is minimal soft tissue covering the organ. Infection can occur at the site of needle insertion; needles should not be placed in areas in which the skin is infected or inflamed. In rare instances, the needle can break (due to patient movement and incorrect placement and removal) and surgery may be needed to remove it.

Some pets require sedation in order to allow insertion of the needles. In some animals, clinical signs may worsen for a few days before they improve. This is not unusual in pets treated with complementary therapies and is explained by the body going through the healing process. In addition, some animals treated with conventional medications also get worse before the medication kicks in.

Many owners worry that acupuncture is painful and their pets will suffer. Usually, it is not painful. Occasionally, the animal will experience some sensation as the needle passes through the skin. Once in place, most animals will relax, and some may become sleepy. Fractious animals may require mild sedation for treatment. Alternatively, a complementary therapy to calm the pet, such as an herbal remedy called Rescue Remedy, can be used prior to and during acupuncture treatment.

Treatments
The number of acupuncture treatments that a pet will require varies. Usually, owners are asked to commit to eight treatments (two to three a week) to assess whether it will work. On average, treatments last about 15 to 30 minutes for needle acupuncture and five to ten minutes for aquapuncture or electroacupuncture. If the pet improves, acupuncture is done as needed to control the symptoms. Other therapies may be used to decrease the number of visits for acupuncture.

While acupuncture can be useful for a variety of disorders, most clients seek therapy for pets with musculoskeletal or neurological disorders.

Scientific Evidence
Numerous reports in the human medical literature attest to the benefits of acupuncture. One study showed 65 percent of people treated with chronic neck and shoulder pain achieved longterm improvement. Another study of 22 patients with chronic low back pain showed a 79.1 percent success rate. Acupuncture was twice as effective as the nonsteroidal anti-inflammatory medication piroxicam.

In pets, one study found 70 percent of dogs with chronic degenerative joint disease (osteoarthritis) showed greater than 50 percent improvement in mobility after treatment with acupuncture. In pets with osteoarthritis, acupuncture has been theorized to work by relieving muscle spasms around the joint, by producing pain relief by stimulating central endorphin releasing systems, by improving blood circulation, by direct anti-inflammatory effects, and by releasing local trigger points and relieving stiffness. Chinese medical theory holds it works by unblocking Qi and blood in the body’s meridians and treating the Bi syndrome.

A proper diagnosis must be made prior to starting therapy. Acupuncture cannot be effective for treatment of osteoarthritis if the pet doesn’t actually have osteoarthritis. Many dogs treated incorrectly for osteoarthritis, in fact, have a neurological disease. This requires different therapy.

Conventional Therapy
Therapies include the use of corticosteroids or nonsteroidal anti-inflammatory medications. Corticosteroids can be given by injection, by mouth, or by both. The most commonly used are prednisone, prednisolone, dexamethasone, and triamcinolone. Injections can be short-acting or longer-acting injections.

While very effective when used to relieve pain and inflammation, they have both short and longterm side effects. Short-term include increased water intake, increased urination, increased appetite, destruction of joint cartilage, and very rarely, either depression or excitability. Long-term effects that can occur include suppression of the immune system, infections, diabetes, liver disease, osteoporosis, Cushing’s disease, and obesity. Side effects are common in dogs but relatively rare in cats.

When needed, short-term use of fast-acting corticosteroids is preferred. Depot (long-lasting) injections, while commonly used in cats, should rarely, if ever, be used in dogs. In cats, an occasional depot injection (one to three a year) is usually not associated with side effects. However short-acting injections and oral medications are preferred. Side effects of NSAID usage include liver disease, kidney disease, ulceration of the stomach and intestinal tract, and possibly further destruction of the joint cartilage.

The safest use of NSAID therapy is combing them with natural treatments designed to restore joint cartilage, as well as relieve pain and inflammation. Once clinical signs improve, NSAIDs are safely used on as needed basis when the pet experiences a particularly painful day.

Ringworm is a common fungal infection mainly affecting puppies and kittens. The disease is highly contagious between pets and may be easily transmitted between infected pets and their owners. Owners should note that most cases of ringworm in people are not caused by exposure to pets, however. Clinical signs in pets include hair loss, usually in a circular or “ring-shaped” pattern. However, ringworm can look like any skin disease. In kittens, tiny scabs (miliary lesions) may also occur in infected pets.

Natural Treatments
Topical therapy with herbal shampoos containing calendula and goldenseal may be helpful. In addition, a natural diet is indicated. Herbs to boost the immune system that help with infections are astragalus, dandelion leaf, echinacea, garlic, German chamomile, Gotu Kola, Oregon grape, sage, turmeric and yellow dock.

These natural treatments are designed to reduce the growth of the fungus and inflammation in pets with allergic dermatitis.

They can be used in conjunction with conventional therapies, as they are unlikely to be effective by themselves in most pets with severe ringworm infections. The natural treatments are widely used with variable success but have not been thoroughly investigated and proven at this time.

As with any condition, the most healthful natural diet will improve the pet’s overall health.

Conventional Therapy
Conventional therapy utilizes medicated shampoos, and in serious infections, oral antifungal medications, usually griseofulvin.

GLUCOSAMINE AND CHONDROITIN constitute the major GAGs in the joint cartilage: glycosaminoglycans serve as major components of articular cartilage. Glycosaminoglycans function by decreasing the presence of harmful pro-inflammatory prostaglandins and other inflammatory enzymes that degrade the cartilage matrix. This results in reduced pain and inflammation, decreased enzymatic destruction of the cartilage, and stimulation of anabolic (cartilage-building) pathways. The GAGs also appear to increase the synthesis of proteoglycans, hyaluronic acid (which acts as a joint lubricant), and collagen.

One novel product called Adequan contains glycosaminoglycans extracted for bovine cartilage and is available in an injectable form. The recommended regimen is a series of eight injections, two each week for four weeks. If the pet has responded favorably during the 4-week trial, the pet is then given an injection as needed (usually one injection every one to 12 months). This injectable product can be used with oral chondroprotective supplements as well. The injectable product can be used to get a faster response than the oral supplements. Further injections are given as needed, or pets can be maintained on oral supplements according to the response seen and the convenience of the pet owner. This product has also shown effectiveness when flushed into joints during joint surgery, allowing faster and smoother recovery.

Side effects with GAGs are extremely rare but are reported to include a dose-dependent inhibition of blood clotting. Concerned owners may want to have their pets' doctors regularly monitor blood coagulation parameters and use homeopathic remedies to help increase blood-clotting factors.

The following points concerning chondroprotective therapy are important to maximize success when using these supplements:

Safety. They are extremely safe and equally effective when compared to NSAIDs.

Cost. This may be an issue for some pet owners. The typical daily cost of using a glucosamine-chondroitin supplement is approximately $1.50/day for a 50-pound dog. This cost can decrease as the dosage of the supplement is lowered to allow the owner to use the least amount to maintain pain relief. The comparable cost of the most popular NSAIDs is approximately $2 to $3 a day for a 50-pound dog making the supplements less expensive, equally effective, and without potentially serious side effects.

Early Diagnosis. Since these supplements work by acting on living cartilage cells, they are most effective when used early in the course of the disease. This requires adequate and early diagnosis.

Response Time. Because they are not drugs but nutritional supplements, the response may not be seen for four to eight weeks. During the four to eight weeks, an increased "induction" dose is used and then the dose is lowered as improvement is seen. Additional short-term therapy (with NSAIDs, acupuncture, or other therapy) can be used during the induction phase.

Effectiveness. The supplements can also be used effectively when no clinical signs are present but yet disease exists. In many practices, a number of dogs are diagnosed via screening radiographs with hip dysplasia and started on the supplements pending a decision on the owner's part for surgical correction or until clinical signs occur.

Product Purity. The purity of products is an important factor. There are many generic knock-off products that sell for much less than patented products produced by reputable manufacturers. Studies have been done showing the effectiveness of these compounds that have used pure grades of products. Products of lesser purity, while often costing less, may also be less effective. Unlike traditional drugs, these compounds are not regulated and labeling can be inaccurate or misleading; manufacturers are not required to analyze their products regarding purity, uniformity, or content. Purchase only quality products from reputable manufacturers as recommended by your doctor.

Recommended Reevaluation. Because the chondroprotective supplements are so effective after four to eight weeks in improving signs seen in arthritic pets, the diagnosis should be reevaluted after this period of time if improvement is not seen.

Shark Cartilage
There is a reported link between blood vessel growth and the development of osteoarthritis as well. The synovial (joint) fluid of arthritic pets includes an increasing amount of a chemical called endothelial cell-stimulating angiogenic factor. This chemical encourages the growth of new blood vessels in the arthritic joint. It is theorized that by inhibiting angiogenesis, further degeneration of cartilage might be prevented.

In the laboratory, shark cartilage has been shown to contain chemicals that inhibit blood vessel formation. Arthritic pets and people taking shark cartilage supplements often experience increased mobility and decreased pain. In one study, eight of ten dogs showed improvement when treated at a dosage of 750 mg/5 kg of body weight for three weeks. When treatment was temporarily discontinued, pain and lameness returned. Administering additional shark cartilage at 50 percent of the original dose resulted in improvement. The relief from pain and inflammation was theorized to occur as a result of decreased blood vessel formation.

Improvement may also result from a relief from pain due to a large number of mucopolysaccharides contained in the cartilage, which can help nourish and heal the cartilage. As a result of studies such as this one, many vets feel it is prudent to prescribe shark cartilage as it can substitute for therapy with medications like non-steroidal drugs that have potential side effects. The main problem with using shark cartilage is the large dosage required. This suggested dosage would require giving a large number of capsules to the pet daily. And since it is among our more expensive supplements, the dosage of shark cartilage needed for medium to large breed arthritic dogs would be unaffordable for most pet owners.

Shark cartilage should not be used in people who have recently suffered a heart attack, in pregnant women, and those who have or are recently recovering from deep surgery. Similar precautions probably apply to pets.

Because of the potential for impure product, owners should consult with their doctors before using shark cartilage.

Several products on the market supply a much lower dosage than that listed in the reported studies. This lower dosage has proved beneficial in some dogs. Because shark cartilage is very expensive to use in larger dogs ($40 to $50 for 2-week supply) some owners are tempted to give less than the recommended dosage. This can be useful after a one to two month stabilization period. Work with your doctor to determine the most effective dose. As is often the case with nutritional supplements, we don't know the best or most effective dose for shark cartilage. Therefore, we must use the products currently available and adapt the dosage to the individual pet's needs.

Perna
Perna canaliculus, the green-lipped mussel, is a shellfish that is a natural source of highly concentrated glycosaminoglycans (GAGs), including chondroitin, as well as a number of other nutrients, including complex proteins, amino acids, nucleic acids, naturally chelated minerals, and an inhibitor of prostaglandin syntheses, which makes it effective as an anti-inflammatory supplement.

Several studies in people have confirmed improvement in patients with osteoarthritis and rheumatoid arthritis. Ongoing studies, as well as anecdotal evidence, show the benefit of Perna in dogs with osteoarthritis. (Benefits in cats are scant, as arthritis is quite rare in cats when compared to dogs. However, veterinarians are using many dog products safely in cats.)

Stabilized powder (Seatone, MacFarlane Laboratories, Surrey Hills, Victoria, Australia) and the lipid extract (Lyprinol, MacFarlane Laboratories, Surrey Hills, Victoria, Australia) showed similar results in people with rheumatoid and osteoarthritis. The lipid extract is a 20-fold concentrate of the originally dried mussel. As is true with the powder form, the lipid extract is believed to be a potent but slow-acting antiinflammatory that inhibits cyclooxygenase and5-lipooxygenase. This is probably via the omega-3 fatty acid content of the mussels. In a laboratory experiment in rats, the dosage of Lyprinol was 20 mg/kg. In studies in people, a dosage of 300 mg twice daily for the first 30 days followed by a dosage of 150 mg twice daily showed positive results. Check with your vet for dog and cat dosages of these products.

Perna is inexpensive and readily accepted by most dogs. A product showing favorable results in pets is called Glyco-Flex Plus; it combines benefits of Perna with MSM.

Sea Cucumber
The sea cucumber, cucumaria frondosa, also known by the names, trepang and beche demer, is a marine animal related to urchins. It is believed these organisms inhibit harmful prostaglandins involved in causing pain and arthritis. They are also rich in nutrients needed by cartilage. One popular product supplies the sea cucumber in a unique jerky-type treat (Sea Jerky-R), which dogs find quite palatable. Other compounds in this product include sea kelp, natural vitamin E, lecithin, garlic, omega-3, and glucosamine hydrochloride. Each treat provides 1200 mg of chondroitin.

In testing by independent laboratories the product showed excellent anti-inflammatory activity in rats. The anti-inflammatory response was superior to that of Rimadyl and phenylbutazone. This study also showed that Sea Jerky-R had higher activity than a product made from Perna mussels and a glucosamine/chondroitin supplement, indicating this product might be preferred if a dog fails to respond to another supplement.

The recommended dosage for this product is one piece of jerky per day for a 60 to 70-pound dog. While it was assumed the active ingredient in the product was chondroitin, further research showed that while the sea cucumber contains chondroitin, another substance called InflaStatin appears to be the active ingredient.

These treats are perfect for the dog that is hard to medicate.

The jerky treats can also be used in conjunction with other similar pill supplements, as it is unlikely to overdose a pet on glucosamine or chondroitin. For those pets with arthritis, most owners and doctors like the idea of giving them a daily treat that is good for them.

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