Prilactone- CEVA

Re: Prilactone- CEVA

Rajat — Tue, 21 Aug 2012 23:16:05 GMT

Sorry I meant 0.7mg/kg not 1.4 for the higher dose!

Re: Prilactone- CEVA

Rajat — Tue, 21 Aug 2012 23:14:07 GMT

[quote user="robloxley"]Yes that was my point. Though it seems there's debate at to the efficacy at 2mg/kg let alone at 0.5mg/kg [/quote]

I'm not sure if aldosterone blocking effect at various doses has been looked at or not in dogs.. but they used 25mg per day in the RALES study upto 50mg in those cases where CHF progressed...around 0.3- 1.4mg/kg for an average bloke weighing 70 kg?

Also David, you mentioned patients in this study were mostly in NYHA Class IV. Just pulled up the paper to have another read. There were 72% in class III 27% in class IV and 1 % class II.

Best

Raj

Re: Prilactone- CEVA

Rob Loxley — Tue, 21 Aug 2012 22:43:58 GMT

[quote user="Thomas Johnson"]I read it as cheaper because you'd be using less[/quote]

Yes that was my point. Though it seems there's debate at to the efficacy at 2mg/kg let alone at 0.5mg/kg

Re: Prilactone- CEVA

Thomas Johnson — Tue, 21 Aug 2012 18:33:18 GMT

[quote user="Martin Atkinson"]

[quote user="robloxley"]I've spoken to a few cardiologists who have suggested a much lower (and cheaper) dose may be effective? [/quote]

Do I detect a heffalump trap here? My bee in the bonnet is companies like CEVA using the cascade as a backdoor to high profitability with limited development costs by 're-inventing' a generic drug as a veterinary ethical. I have no doubts cheaper generic alternatives work as well but be prepared for the VMB to beat a path to your door - I never said I used them

[/quote]

I read it as cheaper because you'd be using less, not because you're using generic spironolactone instead of Prilactone.

Re: Prilactone- CEVA

Martin Atkinson — Tue, 21 Aug 2012 17:56:16 GMT

[quote user="robloxley"]I've spoken to a few cardiologists who have suggested a much lower (and cheaper) dose may be effective? [/quote]

Re: Prilactone- CEVA

Rajat — Mon, 20 Aug 2012 10:30:35 GMT

Hi Hannah

That;s correct- have had no problems in its use. The hyperkalemia seems to be a theoretical concern only, and I have seen no clinical concerns at all with this regard. I have used it in cats that are becoming hypokalemic from diuretic therapy to help conserve potassium and it has worked well in this setting too.

Like Bob, this is my fourth line drug - I prefer to use Frusemide, Pimobendan, Ace inhibitors and Spironolactone in that order in the typical Mitral valve disease dog.

I think the dose range is relatively wide, so I have used from 1-4mg/kg. The 4mg/kg was used in 2 cases a doby with severe CHF and hypokalemia and a cat with Hyperaldosteronism. It was well tolerated in both at these dosed.

Best

Raj

Re: Prilactone- CEVA

David Mills — Sat, 18 Aug 2012 14:50:32 GMT

[quote user="Bob Russell"]

But many very senior cardiologists support its use and are presumably not all in the CEVA pocket.

[/quote]

This may be the case, but the evidence is there for everyone to examine, and at a higher level than expert opinion. All expert opinion is based on something, and it's instructive to examine the quality of this base and whether it stands up to critique. A lot of experts will use ACEi before clinical signs in cats and dogs with acquired heart disease - but there's no evidence for it. I think sometimes we have to be wary of elevating experts to higher evidential levels than is warranted.

Re: Prilactone- CEVA

Bob Russell — Sat, 18 Aug 2012 09:54:13 GMT

But many very senior cardiologists support its use and are presumably not all in the CEVA pocket.

I have to admit it is the drug at the bottom of the list where budget limits drug choice! I did use it a little more before the licenced product arrived because it was a cheap add-on. The high cost is difficult to justify and one of those situations where cascade is being abused by the pharmaceutical company IMO.

Re: Prilactone- CEVA

David Mills — Sat, 18 Aug 2012 01:51:45 GMT

I am very, very suspicious of the true worth of spironolactone as an adjunct therapy.

The main dog study is a CEVA-sponosored study:

http://www.ncbi.nlm.nih.gov/pubmed/20102506

Which, in all honestly, is fatally flawed. It is very oddly designed, with only 39 animals (out of 212) reaching the endpoint, with 94 out of the 212 withdrawing. The diagnosis of CHF in the dogs was based on a wide range of signs, and radiographic pulmonary oedema/LA enlargement/tachypnoea were not an essential components of the diagnosis. Only VHS>10.5 was required. Therefore, a large number of dogs were not in CHF at any point in the study (and the numbers of those on frusemide are not outlined). Inclusion was via a wide range of experiences - 1st opinion to specialist. Although spironolactone appears to show a benefit the fact that many dogs weren't in CHF means that it is impossible from this study to say whether its of benefit in CHF.

And, as for low dose - appears to be a complete waste of time (or as much of a waste of time as higher dose?):

http://www.ncbi.nlm.nih.gov/pubmed/20950346

The RALES study is oft-touted example of spironolactone's overwhelming benefit in humans - with the fact it was stopped early being particularly seductive. However, the patients recruited in this study were in NYHA IV mainly - i.e. severe heart failure with inability to do any physical exercise - equivalent to ISACHC IV (i.e. specialist hospitalisation intervention required). To extrapolate this to all forms of veterinary CHF is of very questionable validity.

Although widely used in humans, spironolactone is not without risks, the main being hyperkalaemia especially in conjunction with ACEi. In the US ulcerative facial dermatitis was seen in around 30% of cats given the drug at 2mg/kg - not reported in UK.

I simply don't think the evidence is available to say it extends life, despite the theoretical benefits and the aggressive CEVA marketing. The high cost (cf generic spironolactone), I think, is very difficult to justify to clients with such weak (any?) evidence - and with the studies around anecdote has no place.

Re: Prilactone- CEVA

Stephen Courtney — Fri, 17 Aug 2012 22:34:27 GMT

I always use it if I can, including for my own dog. Frusemide, pimobendan, ACE inhibitor and prilactone are my standard approach if budget allows

I have never felt it did any harm, and i am convinced by the literature and my own experience. these dogs live way longer than they used to. Hard to be sure how much comes down to any one drug in real life but I am like everyone, else, take what credit i can when my actions work out well!

By the way, I also use prilactone in cats pretty freely too. never a problem providing they are pillable or will take it in food.

And that brings my final point, spironolactone is fat soluble so best given with food

Re: Prilactone- CEVA

Hannah Ridgwell — Fri, 17 Aug 2012 20:27:08 GMT

Hello again,

Thanks for your prompt response. I take it from your reply you haven't had any actual problems whilst using spironolactone.

Hannah

Re: Prilactone- CEVA

Rob Loxley — Thu, 16 Aug 2012 23:33:07 GMT

Does anyone know where the 2mg/kg dose rate comes from: I've spoken to a few cardiologists who have suggested a much lower (and cheaper) dose may be effective? Also we always split down the larger tablet sizes to make the cost less prohibitive.

Re: Prilactone- CEVA

Rajat — Thu, 16 Aug 2012 19:55:57 GMT

Hi hannah

Yes I do use it in dogs with CHF - difficult to say how I find it as like with any cardiac med other than frusemide(and maybe pimo in dogs with poor systolic function) a positive response is tough to call on an individual basis in the short term.

But there is evidence it works, and if you ask the CEVA guys they will send you some clinical data including round table talks between huiman and vet cardios illustrating its benefit. Yes it is made to look pretty to convince us. The human Rales study famously was stopped early because of the marked benefit in mortality humans with heart failure taking Aldosterone antagonists. Obviously with different diseases than dogs get but they have shown dogs do get fibrosis with mitral valvular disease too.

I think it is a pain to have to use prilactone cf spironolactone generic re cost but hey ho..

Cheers

Raj