Patients with acute disease, including those with fever, tachypnea, tachycardia, systemic inflammatory syndrome, or circulatory shock, should be hospitalized and aggressively treated.
Crystalloid fluids are a mainstay of treatment, providing perfusion of the inflamed pancreas as well as cardiovascular support. Treatment goals should include replacement of circulating fluid volume and maintenance of pancreatic perfusion to prevent necrosis. Colloids can be added to provide oncotic support, and fresh frozen plasma can be added to replace coagulation factors. Initial resuscitation can involve a combination of crystalloid and colloid fluids. Electrolyte abnormalities (eg, hypokalemia, hypocalcemia) should be anticipated and treated when identified.
Analgesia is important, but pain can be difficult to identify in cats. Narcotics, including parenteral and transdermal fentanyl (4 µg/kg/hour transdermal patch [12 µg/hour patch or 25 µg/hour patch in larger cats] or 1-5 µg/kg/hour CRI; Schedule II), are usually most effective. Buprenorphine (0.01-0.03 mg/kg buccally; Schedule III) can be used initially while fentanyl reaches therapeutic effect, usually within 12 to 24 hours.
Vomiting should be controlled to facilitate patient comfort and minimize fluid loss. Multiple antiemetic agents are often necessary to control emesis. Maropitant (1 mg/kg SC every 24 hours or 2 mg/kg PO every 24 hours) has antinociceptive effects in addition to antiemetic properties and can be used alone or with a 5-HT3 receptor antagonist (eg, ondansetron, 0.5 mg/kg IV loading dose, followed by 0.5 mg/kg/hour CRI for 6 hours or 0.5-1 mg/kg PO every 12-24 hours; dolasetron, 1 mg/kg IV or PO every 24 hours).
Because diabetes mellitus is a common comorbidity, glucose should be closely monitored and maintained in a normal range. Even mild hyperglycemia should be corrected with small amounts of insulin (regular insulin, 0.1 U/kg IM every 6-8 hours) to help prevent further damage to the pancreas and diabetes mellitus as a sequela to pancreatitis.
Prednisolone can be beneficial for treatment and/or prevention of chronic pancreatitis because of anti-inflammatory and antifibrotic activities. Standard treatment protocols are not available; recommendations have been made for anti-inflammatory (0.5-1 mg/kg PO every 24 hours) and immunosuppressive dosages (1-2 mg/kg PO every 12 hours).17 Development of diabetes mellitus is a potential adverse effect; cats receiving prednisolone should undergo frequent serum glucose evaluations. Serum fPLI can be measured to detect resolution of inflammation. Cyclosporine (5 mg/kg PO every 24 hours) can be used in cats that do not tolerate prednisolone.
It is crucial to provide adequate nutrition early, as pancreatitis can lead to hepatic lipidosis. Appetite stimulants (eg, mirtazapine, 1.88-3.75 mg per cat PO every 24 hours or 2 mg per cat transdermal on ear pinna every 24 hours) are effective in cats. Cyproheptadine (1 mg per cat PO every 12 hours), a histamine H1- and 5HT-receptor antagonist, can also be used but has limited efficacy.
In cats that remain anorexic, feeding tubes can be used to deliver enteral nutrition. Nasoesophageal tubes can be placed in cats that can maintain an upright position. Esophagostomy tubes, which can be placed as soon as the cat can be anesthetized, allow administration of a larger variety of foods and can be managed at home on a long-term basis. Hydration can be maintained via water supplementation through the tube.