'Standard' CRI management in dogs

Re: 'Standard' CRI management in dogs

james herriot lied — Fri, 18 Jan 2013 16:00:10 GMT

Andrew, I consider you to be out of order here. Please leave me alone. I don't want a fight, or an endless, drawn-out argument over what you feel. Just leave it, please.

Re: 'Standard' CRI management in dogs

Andrew Kent — Fri, 18 Jan 2013 15:56:56 GMT

[quote user="james herriot lied"]

[quote user="Andrew Kent"]

Any you seem to meet any suggestion with indignation and negativity so really anybody who tried to help couldn't win!

[/quote]

Yeah, that's really not true at all. We'll leave it there, as again there just seems to be a descent into sniping.

[/quote] Well then you should probably consider the way you word your replies before attaching those who try to help! But I'm sure we have all learnt not to make as many suggestions in the future. Have a good weekend.

Re: 'Standard' CRI management in dogs

james herriot lied — Fri, 18 Jan 2013 15:52:43 GMT

[quote user="Andrew Kent"]

Any you seem to meet any suggestion with indignation and negativity so really anybody who tried to help couldn't win!

[/quote]

Yeah, that's really not true at all. We'll leave it there, as again there just seems to be a descent into sniping.

Re: 'Standard' CRI management in dogs

Andrew Kent — Fri, 18 Jan 2013 14:31:03 GMT

[quote user="james herriot lied"]I'd counter, though, that statements like 'I'm at a loss as to [why you would do this]' are, essentially, demonstrating a lack of respect for my skills and knowledge; they might not be meant that way, but that's most certainly how they come across.[/quote]

If this is referring to:

[quote user="Andrew Kent"]I'm a bit lost as to what you are suggesting swapping for an ACEi [/quote]

Then if you read it closely you will see that I was lost as to following your post as to what you were suggesting swapping, it was not directed at all at your choices so please don't read between the writing.

Once again I apologise if any comments seemed out of place but you got answers to what you asked, so to then be annoyed about it seems a little unfair on the people who try to help. Any you seem to meet any suggestion with indignation and negativity so really anybody who tried to help couldn't win!

Re: 'Standard' CRI management in dogs

mariette asselbergs — Fri, 18 Jan 2013 14:23:48 GMT

"She hasn't got a hope of affording pancreatic extract for the dog."

In that case you can suggest that she gets pancreas (pig pancreas usually) from a butcher's. It6 works wonders in EPI dogs. And is dead cheap if you have the right butcher....

Mariette

Re: 'Standard' CRI management in dogs

james herriot lied — Fri, 18 Jan 2013 12:31:33 GMT

[quote user="Andrew Kent"]

Why ask for suggestions if you are going to take offence when they are offered?

I don't think the tone of any bodies posts were particularly combative and certainly mine were not meant in that way so I apologise if that is how they came across. Often I post in a hurry between other things so don't always have time for small talk ;-)

if you only want specific comments then ask for them specifically, otherwise you will get the kind of comments that you did with the best of intentions from all the posters.

[/quote]

No, I don't think so. I'm not taking offence at anybody, merely noting that there seems to have been a recent trend where posters canvass for opinions, but often find themselves having to justify their treatment against inferrals of inadequacy; equally, a common assumption that other people aren't quite as clever as oneself, and must therefore be taken to task for their lack of knowledge. It's a feeling, rather than a particularly concrete theory, but it seems to be on the up.

I'd counter, though, that statements like 'I'm at a loss as to [why you would do this]' are, essentially, demonstrating a lack of respect for my skills and knowledge; they might not be meant that way, but that's most certainly how they come across. I really do have a vet degree, and 20 years of making mistakes and learning, always learning. I'm delighted to have access to some fairly cutting edge opinions on here, but that doesn't mean I don't know what I'm doing (generally). If I can't keep a dog on the combination of CHF treatments that I would like, it's because circumstances are stopping me, not my own clinical reasoning. Some of us work in relatively poor areas, in first opinion GP work, and yet are still able to speak with the big words and difficult concept things.

On the other hand, if people want a discussion about eugenics or the usefulness of homeopathy, then one would expect the discussion to become rambunctuous and a bit mud-slingy. Only to be expected.

Not arguing, not looking for a fight. Just wondering whether there are any new advances with which I should be acquainted. I've had that one answered. Many thanks to all.

Re: 'Standard' CRI management in dogs

Mike Martin — Fri, 18 Jan 2013 12:16:11 GMT

[quote user="james herriot lied"](urea 35, crea 200, phos 2.48, urine sg 1.012 with trace protein, PCV 31).[/quote]

I sometimes see these figures in CHF dogs on moderate to high dose of frusemide. Just something else for everyone to keep in mind. I'm aware it probably does not apply in this case, as you have said the frusemide dose is low and I presume the diagnosis of CRF was prior to the heart failure treatment. U SG will be low on dogs once they start frusemide and probably UPC would be of little value for the same reason I suspect.

The cheapest way to treat heart failure cases is to use the cheaper alternative drugs, higher tablet strengths but cut into smaller sizes and use a lower end of the wide dose range.

Good luck anyway.

Snow is settling here :)

Re: 'Standard' CRI management in dogs

Rajat — Fri, 18 Jan 2013 11:42:51 GMT

[quote user="Andrew Kent"]

if you only want specific comments then ask for them specifically, otherwise you will get the kind of comments that you did with the best of intentions from all the posters.

[/quote]

I was thinking the same - JHL no offense meant from what I said- I don't think I told you what to do either just mental ramblings and thoughts on what I would do. I couldn't be feeling further from combative, currently got a DGAF attitude! But the snow is cheering me up. Maybe we all have that seasonal sunlight deficiency disorder, I forget the proper name.

Re: 'Standard' CRI management in dogs

Andrew Kent — Fri, 18 Jan 2013 10:45:53 GMT

[quote user="james herriot lied"]

Yes, we do have clinical signs which could be consistent with thyroid - some strange neuro signs which, were there pain present could be consistent with syringomyelia (although it would, by some margin, be the oldest onset that I've come across) - and boy, would I like to image all of that. But we basically were planning to do some rads/scanning the other day, and did bloods instead - no funds for both - stretched to some fluids and treatment as described.

We can't afford both vetmedin and fortekor. We're on low dose thyroxine and low dose frusemide. EFA supplements are being given by owner. Renal diet is being fed.

I would like to do follow-up thyroid work, proper imaging of head/neck, chest and abdo (did I mention the recent bout of pancreatitis?). I'd like to be on a combo of cardiac drugs. UPC would be nice, but not essential in view of likely treatments for cardiac disease. But I can't. I think sometimes there's this belief that people can afford to do these things, but in reality they can't. Last week, I found an EPI in a young spaniel. The owner can't afford to feed her kids at the moment, and is relying on food banks. She hasn't got a hope of affording pancreatic extract for the dog.

I appreciate the opinions, certainly. But perhaps not the assertions that I must do this or that. I know of these things, being qualified and everything, so if I'm not doing them, there's a reason for it. What I was really looking for were genuinely new ideas, or else confirmation that actually, we're all still in the same boat.

Is it just me, or is the entire forum a bit combative at the mo?

[/quote] Why ask for suggestions if you are going to take offence when they are offered?

if you only want specific comments then ask for them specifically, otherwise you will get the kind of comments that you did with the best of intentions from all the posters.

Re: 'Standard' CRI management in dogs

Anthony Dennison — Fri, 18 Jan 2013 09:34:17 GMT

[quote user="james herriot lied"]Genuinely lovely owner, but serial bloods and some fluids have exhausted the funds: currently she's borrowing money from family for the vetmedin[/quote]

If costs are an issue, Cardisure is a cheaper alternative to Vetmedin, and tablet sizes make for easier dosing too

Re: 'Standard' CRI management in dogs

james herriot lied — Fri, 18 Jan 2013 09:21:08 GMT

We can't afford both vetmedin and fortekor. We're on low dose thyroxine and low dose frusemide. EFA supplements are being given by owner. Renal diet is being fed.

Is it just me, or is the entire forum a bit combative at the mo?

Re: 'Standard' CRI management in dogs

Rajat — Thu, 17 Jan 2013 23:08:52 GMT

[quote user="james herriot lied"]Nobody has come out in favour of 'roids, for example.[/quote]

I am very pleasantly surprised about that!! Though I have a feeling Anthony might set that right soon!

Re: 'Standard' CRI management in dogs

Rajat — Thu, 17 Jan 2013 23:07:32 GMT

[quote user="james herriot lied"]

Alas, funds preclude a combo. Genuinely lovely owner, but serial bloods and some fluids have exhausted the funds: currently she's borrowing money from family for the vetmedin. And no, it's not a put-up or emotional blackmail from the client - I found out elsewhere. These clients do exist, peeps.

So, I'm minded to use an ACEi as a deterrent to hypertension, and any undetected proteinuria. I think frusemide is at lowest useful dose. A little thyroxine may combat some drop in gfr without pushing it through the roof and a combination of renal diet and/or phosphate binder will form the backbone. Pretty much everything on my watch gets EFAs.

So, I'm not missing WondaGlom, the 'secret' human generic which everybody in the know has been using for the last couple of years?

[/quote]

[quote user="james herriot lied"]

So, I'm not missing WondaGlom, the 'secret' human generic which everybody in the know has been using for the last couple of years?

[/quote]

If funds preclude it, stick to pimobendan as it has got the stronger evidence base for prolonging life with CHF than ace inhibitors. Also it will prob increase actual cardiac output to the kidneys which should help...

I am not sure ace inhibitors act 'as a deterrent' to hypertension or they are of much use as a sole agent in hypertension in dogs and cats ..only modest reductions in BP are seen with their use and I would suggest saving the client's money for the pimobendan in this scenario...I would not spend money on thyroxine unless clinically hypothyroid either but I am sure you have gone through the rigmorale of thyroid testing already ...interestingly increasing GFR in a failing kidney also unlikely to help the dog live longer, though it may feel better temporarily, increasing the glomerular pressure in a kidney with fewer glomeruli leads to higher individual trans-glomerular pressures, more glomerular damage/sclerosis and a worsening long term outlook if I remember correctly.

I think it is very important to do the basics right first in these cases which you are- control phosphate religiously as per IRIS guidelines which are lower than most lab reference ranges, ensure hi dose EFAs on board (heart and kidneys both benefit) ensure lowest effective dose of furosemide, keep on renal diet and things like b12/multivitamin injections (the latter are cheap as chips!)

Re: 'Standard' CRI management in dogs

Andrew Kent — Thu, 17 Jan 2013 22:05:14 GMT

[quote user="james herriot lied"]

OK, here's a question. How would a UPC test change anything in this dog's management or prognosis right now?

[/quote] Because if the dog is proteinuric then you have another reason to suggest adding an ACEi to control this and the owner then has a choice whether to do it or not.

I'm a bit lost as to what you are suggesting swapping for an ACEi but I don't think you can swap either of your current cardiac meds without destabilising the disease.

Re: 'Standard' CRI management in dogs

Stephen Courtney — Thu, 17 Jan 2013 21:50:08 GMT

True. Things look grim, but a relatively cheap test might make it easier to persuade owners to look more realistically at the big picture.

Managing end stage CHF and renal disease is a nightmare. End of.

Re: 'Standard' CRI management in dogs

james herriot lied — Thu, 17 Jan 2013 21:45:44 GMT

OK, here's a question. How would a UPC test change anything in this dog's management or prognosis right now?

Re: 'Standard' CRI management in dogs

Stephen Courtney — Thu, 17 Jan 2013 21:35:20 GMT

I doubt the dog is really hypothyroid, she sounds pretty sick and i think that any TSH/TT4 will be suspect.

i would certainly consider a Urine P:C

I would also prefer to keep this dog on vetmedin AND an ACEi, i also like spironolactone, have you looked into using cardalis? Generally works out cheaper. i offer written Rx to clients in constrained circumstances, rather than waiting for them to ask for one.

I will use cerenia and mirtazapine fairly freely in anorexic dogs for whatever reason, often helps, in the short term to buy some time

If the kidneys are really bad ( likely, I fear, given those values) the dog is not going to do well at all, and if the client has no resources it might be kinder to pull the plug.

Re: 'Standard' CRI management in dogs

james herriot lied — Thu, 17 Jan 2013 21:31:31 GMT

Not stopping the frusemide. By combo I'm referring to vetmedin plus an ACEi.

Wouldn't be absolutely sure about effects of frusemide on blood pressure either, particularly as doses ramp up. Always had concerns about RAA activation - which is why I'd always be covering with an ACEi if dose was high.

Do you know, though, we used to stick them all on frusemide and millophylline. And some of them lived for literally weeks.

Re: 'Standard' CRI management in dogs

Andrew Kent — Thu, 17 Jan 2013 21:09:20 GMT

I think you will be lucky to control the CHF without frusemide and would think the frusemide is a fairly small part of the cost. Hypertension in renal disease evolves due to sodium retention so it is almost impossible for the dog to become hypertensive on frusemide.

Re: 'Standard' CRI management in dogs

james herriot lied — Thu, 17 Jan 2013 20:30:10 GMT

So, I'm not missing WondaGlom, the 'secret' human generic which everybody in the know has been using for the last couple of years?

Re: 'Standard' CRI management in dogs

Andrew Kent — Thu, 17 Jan 2013 18:06:12 GMT

I wouldn't swap to am ACEi, I would add it in addition, frusemide still needs to be the backbone of CHF management, just at the minimum effective dose.

Re: 'Standard' CRI management in dogs

james herriot lied — Thu, 17 Jan 2013 17:40:03 GMT

Yep, all good answers and I take the point about UPC. Should have said, we started the renal diet today and will be modifying according to eagerness to eat - antacids first, followed by reversion to a standard diet plus phosphate inhibitor. Already on EFAs and normotensive - think someone suggested that one - and on low dose frusemide at half a 20mg BID - and yes, there was significant evidence of clinical CHF before starting. Lytes were normal today.

I'm minded to swap to an ACEi after some thought, partly because of the potential for protein sparing (although not convinced this is happening in this patient) and partly because I'm not really expecting a particularly long term outcome - the dog has other issues too!

But nobody has that special insight which we don't all already possess, I think. Nobody has come out in favour of 'roids, for example.

Re: 'Standard' CRI management in dogs

Rajat — Thu, 17 Jan 2013 17:15:30 GMT

[quote user="Rajat"]

Hi JHL

Others have rauied very pertinenent and important points. As she appears to be in CRI/CRF as you know it is vital to know that she absolutely needs furosemide. Has she had an echo or episodes of documented (radiographs? sleeping resp rates?) pulmonary oedema?

I would also use ace inhibitors here, not so sure of spironolactone being necessary/needed though it 'may ' help. But not for diuresis.

Have you cultured the urine? UTIs can be quiescent on microscopy ure you know that too

One intervention which has a very high level of evidence (for dogs in CRF) for it is Calcitriol. Have been playing with it a little bit. I can send you some info on it if you like (protocols) - I have tons lying around but here's the paper I refer to

http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2010.00932.x/abstract;jsessionid=96C114FC4565C864D92CCEDA923C9D17.d03t02?deniedAccessCustomisedMessage=&userIsAuthenticated=false

Other things to consider are checking BP and starting high dose omega 3 supplementation. Hate treating CRI and CHF together, what a pain the arse!

[/quote]

sorry i cannot spell today!!

Re: 'Standard' CRI management in dogs

Rob Loxley — Thu, 17 Jan 2013 16:53:38 GMT

+1 for urine P:C ratio and looking closely about frusemide dose needed
also while the evidence says if choosing between an ACEi or pimobendan (+frus) for CHF the latter is better, the rationale for ACE inhibition in CHF hasn't disappeared, and (obviously anecdotal) experience suggests that ACEi plus Pimo (+frus) does better than either alone.

Re: 'Standard' CRI management in dogs

Rajat — Thu, 17 Jan 2013 16:08:12 GMT

Hi JHL

I would also use ace inhibitors here, not so sure of spironolactone being necessary/needed though it 'may ' help. But not for diuresis.

Have you cultured the urine? UTIs can be quiescent on microscopy ure you know that too

http://onlinelibrary.wiley.com/doi/10.1111/j.1748-5827.2010.00932.x/abstract;jsessionid=96C114FC4565C864D92CCEDA923C9D17.d03t02?deniedAccessCustomisedMessage=&userIsAuthenticated=false

Other things to consider are checking BP and starting high dose omega 3 supplementation. Hate treating CRI and CHF together, what a pain the arse!