Pimobendan

Re: Pimobendan

Thomas Johnson — Wed, 22 Apr 2015 18:29:49 GMT

[quote user="Martin Atkinson"]

[quote user="Thomas Johnson"]And I'm afraid I'm going sound like Mr Todd here, shouldn't we be treating the patient not the numbers, just because we can get the proBNP to come down, does that mean we are changing the outcome for the patient?[/quote]It is largely irrelevant as I would use pimobendan now anyway and have been doing for several years. My aim is to keep the patient in B1 on a current status assessment and monitor with a combination of biomarkers, X-ray, ECG, echo and monitoring heart and respiratory rates. I want to prevent it reaching B2 with pre-emptive treatment whatever the choice of that.

[/quote]

I agree it's now a moot point!

Re: Pimobendan

Martin Atkinson — Wed, 22 Apr 2015 17:37:19 GMT

Re: Pimobendan

Thomas Johnson — Wed, 22 Apr 2015 17:03:53 GMT

[quote user="Martin Atkinson"]

[quote user="Thomas Johnson"]

There is some evidence that benazapril will help delay onset of CHF due to DCM:

But for MVD the evidence suggests there is no benefit:

[/quote]Anecdotal evidence certainly but I understood that in humans with MVD they were put on ACEi as soon as there was a murmur. True there was no evidence that this works for MVD in animals but as one of the functions of ACEi is anti-hypertensive and reduction of cardiac after-load which is why they use it in humans there is clear logic in the use to reduce the work load on a stressed heart. Just because there are no symptoms of cardiac failure doesn't mean the heart isn't compensating. Try doing a few NT-proBNP tests if you're not sure and you may be surprised what they tell you.

And we're all jumping to the conclusion that the only drug trialled in the EPIC study was pimobendan - perhaps we ought to wait until the results of trial are published before we draw that conclusion!

[/quote]

The second trial I linked to had 116 dogs receiving an ACE inhibitor and 113 receiving a placebo, and there was no significant difference between the two groups for onset of heart failure, so both groups de-compensated at around the same time. I'm assuming they were using the same criteria for both groups. And I'm afraid I'm going sound like Mr Todd here, shouldn't we be treating the patient not the numbers, just because we can get the proBNP to come down, does that mean we are changing the outcome for the patient?

Re: Pimobendan

Martin Atkinson — Wed, 22 Apr 2015 16:56:22 GMT

[quote user="Thomas Johnson"]

There is some evidence that benazapril will help delay onset of CHF due to DCM:

But for MVD the evidence suggests there is no benefit:

Re: Pimobendan

Robin Grimmer — Wed, 22 Apr 2015 16:51:24 GMT

[quote user="Thomas Johnson"]

[quote user="Hannah Wynne Richards"]

Total agreement with Martin.

Talk about going round in circles.

We were taught to start treatment as soon as murmurs became audible, as preventing the stretching of heart muscle delayed progression of the disease, and increased longevity.

[/quote]

I'm guessing this goes back to before pimobendan was available, so which drugs would you have used to delay progression of which cardiac disease?

Diuretics such as furosemide on their own will up-regulate the renin-angiotensin-aldosterone-system, so might make things worse. There is some evidence that benazapril will help delay onset of CHF due to DCM:

http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2009.0346.x/full

But for MVD the evidence suggests there is no benefit:

http://www.ncbi.nlm.nih.gov/pubmed/11822810

[/quote]

I agree. Diuretics on their own will activate the RAAS and make things worse. ACE inhibitors have afaik not been proven to delay onset of ccf in dogs with heart murmurs. So if this is so, this is a first for pimobendan.

Re: Pimobendan

Michael Woodhouse — Wed, 22 Apr 2015 16:43:37 GMT

[quote user="Hannah Wynne Richards"]We were taught to start treatment as soon as murmurs became audible, as preventing the stretching of heart muscle delayed progression of the disease, and increased longevity.[/quote]

Is that ANY murmur? The great majority of dogs with murmurs can live a long and fulfilling life free from clinical heart disease. If you are putting everything with a grade I or II on pimobendan I suspect they do enjoy a long and fruitful life, as they would have done without the pimobendan..........

Does anyone have a stat for the proportion of dogs with a murmur detected that go on and get disease?

Re: Pimobendan

Thomas Johnson — Wed, 22 Apr 2015 16:03:34 GMT

[quote user="Hannah Wynne Richards"]

Total agreement with Martin.

Talk about going round in circles.

We were taught to start treatment as soon as murmurs became audible, as preventing the stretching of heart muscle delayed progression of the disease, and increased longevity.

[/quote]

I'm guessing this goes back to before pimobendan was available, so which drugs would you have used to delay progression of which cardiac disease?

http://onlinelibrary.wiley.com/doi/10.1111/j.1939-1676.2009.0346.x/full

But for MVD the evidence suggests there is no benefit:

http://www.ncbi.nlm.nih.gov/pubmed/11822810

Re: Pimobendan

Hannah Wynne Richards — Wed, 22 Apr 2015 15:07:43 GMT

Total agreement with Martin.

Talk about going round in circles.

We were taught to start treatment as soon as murmurs became audible, as preventing the stretching of heart muscle delayed progression of the disease, and increased longevity.

It then became fashionable to delay treatment until the animalstarted to get water-logged - because no-body in academia had PROVEN a benefit (not really looked is what they actually meant)

Now pre-emptive treatment has been shown to be advantageous.

I think this is a classic example where experience based medicine has (until recently) been better than evidence based medicine.

Wynne

Re: Pimobendan

Anthony Dennison — Wed, 22 Apr 2015 11:32:00 GMT

[quote user="Martin Atkinson"]Damn I never found the Merial sweet shop![/quote]

Didn't miss much - couple of small scoops of sweets. Mine went in under 5 minutes. It was against the back wall, just to the left of the entrance to the bar as you looked at it.

Re: Pimobendan

Mark Hedberg — Wed, 22 Apr 2015 11:30:49 GMT

[quote user="Martin Atkinson"]

Damn I never found the Merial sweet shop!

[/quote]

'Twas next to the pub - no wonder you never found it! :D

Re: Pimobendan

Martin Atkinson — Wed, 22 Apr 2015 11:02:51 GMT

[quote user="Anthony Dennison"]Probably didn't read it right, only noticed it on the way to the bar and the Merial sweet shop.[/quote]Damn I never found the Merial sweet shop!

More seriously, I also did a double take at the Boehringer stand and questioned them on this very matter. Indeed, their poster was just advertising the use of Vetemedin in preclinical DCM as per the QUEST trial. They were aware that the result of the EPIC trial was known but hadn't inwardly digested it yet as it was less than a month so were unable to give advise on the use of pimobendan in MVD CHF and admitted I probably knew more than them as I'd heard it from the horse's mouth. They said it would probably be October before they were able to act on the results and recommend Vetmedin for this purpose.

So folks you heard it here first.

Re: Pimobendan

Thomas Johnson — Wed, 22 Apr 2015 10:50:54 GMT

[quote user="Anthony Dennison"]

Have to admit I didn't actually stop to read anything, but at BSAVA the big poster at the Boehringer stand said Vetmedin was licensed for use in Dobermans with pre-clinical DCM, not general pre-clinical CHF?

Probably didn't read it right, only noticed it on the way to the bar and the Merial sweet shop.

[/quote]

At BSAVA they were publicising the paper that showed pimobendan delays onset of CHF in dogs with pre-clinical DCM. The paper showing benefits in treating pre-clinical mitral valve disease hadn't been published at that time, but they were mentioning it to people at the same time.

Re: Pimobendan

Anthony Dennison — Wed, 22 Apr 2015 09:25:18 GMT

Probably didn't read it right, only noticed it on the way to the bar and the Merial sweet shop.

Re: Pimobendan

Martin Atkinson — Tue, 21 Apr 2015 15:52:58 GMT

Boast of the day. I was (probably) the first vet in the UK not involved in the trial to know the results of the EPIC study. Mark Patteson told me 5 minutes after he was officially allowed to release them over a beer in the Dolomites skiing. Did I mention SPVS Snowscene somewhere else?!

Mind you I've been pre-emptively treating dogs with MVD cardiomegaly for years from my own anecdotal evidence, I didn't need a survey to tell me they went longer before going into CHF and lived longer.