Angiotensin receptor blocker in canine proteinuria

RE: Angiotensin receptor blocker in canine proteinuria

Andrew Kent — Thu, 15 Dec 2016 12:15:44 GMT

Hi Charlie,

I suspect that one ACEi was started for the proteinuria and one for the heart disease but agree you don't need both.

Your UPC is high but not excessive so you likely have some time to come up with a solution.

If the dog is hypertensive then that is likely contributing to the high UPC so I agree treating that (with higher ACEi dose or amlodipine) would be reasonable but I would want to know what is going on with the heart before messing too much with blood pressure.

So I agree that further investigation of the heart would be a good first step then medication adjustment.

Andy

RE: Angiotensin receptor blocker in canine proteinuria

Charlie G — Wed, 14 Dec 2016 22:51:15 GMT

This did confuse me, I have never used ramipril and wasn't sure whether there is any difference between this and benazepril in terms of efficacy etc. The dog definitely needs a cardiac work up as murmur is currently g3 and still in normal sinus rhythm. Anyway the UPCR came back at 1.96, still awaiting an SDMA result. I was thinking about stopping one of the ACEIs, then maybe adding amlodipine to reduce the hypertension (esp as I thought BP might increase further if I drop one of the ACEIs) and poss repeat sediment analysis etc to ensure still no evidence of post-renal causes... Seems to be a tricky one.

RE: Angiotensin receptor blocker in canine proteinuria

Martin Atkinson — Tue, 13 Dec 2016 15:27:19 GMT

[quote user="Andrew Kent"] I agree there is no benefit (and indeed some potential risks) from being on 2 different ACEi - using an appropriate dose of one would be more sensible.[/quote]I can say this safely as Charlie G inherited this case, but what would possess a vet to put a dog with CHF on 2 different ACEis, proteinuria or not, when there is a much better drug out there in pimobendan if you're gong to add a second agent? Do these people not go to the same CPD meetings as the rest of us? Pimobendam would be No1 choice to start with anyway.

RE: Angiotensin receptor blocker in canine proteinuria

Andrew Kent — Tue, 13 Dec 2016 13:44:09 GMT

[quote user="Martin Atkinson"]

[quote user="Charlie G"]I've just taken over a case of a dog with persistent renal proteinuria, who is currently receiving benazepril, and also on ramipril for CHF. [/quote]I would question first why this dog is on 2 ACEis for its CHF. I would see no benefit in adding in telmistartan as well and as there is no independent research (albeit I respect Andrew's anecdotal evidence) which shows that is better than benazepril for managing proteinuria I wouldn't swap it either as the heart is benefiting. Perhaps a better combo would be benazepril and pimobendan but I would probably drop the ramipril especially if you do decide to add in the Semintra.

[/quote]

Sorry had overlooked that bit - I agree there is no benefit (and indeed some potential risks) from being on 2 different ACEi - using an appropriate dose of one would be more sensible.

And, as I said earlier on, I tend to switch to telmisartan rather than add but accept that that could risk causing issues with the CHF.

I think it all depends on how high the UPC is

Andy

RE: Angiotensin receptor blocker in canine proteinuria

Martin Atkinson — Tue, 13 Dec 2016 10:54:07 GMT

RE: Angiotensin receptor blocker in canine proteinuria

Charlie G — Tue, 13 Dec 2016 10:33:44 GMT

Hi Andy,

Thanks for your advice, he's a very elderly little chap so I'm not sure they'd be very keen to pursue a renal biopsy, but will certainly have a chat with them about it. May well give telmisartan a go if this UPCR is no better.

Charlie

RE: Angiotensin receptor blocker in canine proteinuria

Andrew Kent — Sun, 11 Dec 2016 12:37:40 GMT

[quote user="Charlie G"]

Hi Andy,

I've just taken over a case of a dog with persistent renal proteinuria, who is currently receiving benazepril, and also on ramipril for CHF. His UPCR hasn't improved on the benazepril, but he isn't azotaemic and his PUPD has improved. Would you still consider telmistartan in a non-azotaemic patient with persistently elevated UPCR (I haven't yet received his previous results but have just sent off for another UPCR). His BP when I examined him was 160-170av.

Many thanks,

Charlie

[/quote]

hi Charlie,

i still try to manage significant proteinuria even if not azotaemic as the theory is that ongoing proteinuria leads to progression of CKD so the better we can control it the better the long-term prognosis.

Difficult to say for sure what I would do in your case without knowing more but telmisartan could be an option.

Renal biopsy might be something else to consider as well.

Andy

RE: Angiotensin receptor blocker in canine proteinuria

Charlie G — Sun, 11 Dec 2016 09:47:12 GMT

Hi Andy,

Many thanks,

Charlie

RE: Angiotensin receptor blocker in canine proteinuria

Andrew Kent — Thu, 08 Dec 2016 21:00:32 GMT

[quote user="Stephanie Fursland"]What dose do you start on?[/quote]

The dosing in dogs is poorly described, there is an experimental study that used 1mg/kg SID (as in cats) and a case report that used 0.5mg/kg SID with good response.

I typically start at 0.5mg/kg with a view to doubling if the response is poor.

Andy

RE: Angiotensin receptor blocker in canine proteinuria

Stephanie Wellings — Thu, 08 Dec 2016 19:11:46 GMT

Hi Andy,

Thanks! We started on the standard dose, then doubled the dose of the benazepril (now on 10mg SID in a 12kg dog). I am a bit concerned that even this dose has caused an increase in the azotaemia, although that might be just progression as it is over about 10 months, but trying telmisartan instead might be an idea. What dose do you start on?

RE: Angiotensin receptor blocker in canine proteinuria

Andrew Kent — Thu, 08 Dec 2016 18:29:27 GMT

Hi Stephanie,

We use telmisartan fairly frequently in dogs who are poorly responsive to ACEi and it does seem effective in some cases who have failed that first treatment.

There is some concern about electrolyte disorders when ACEi and ARB's are used together (although that seems to be more significant in people than dogs), for that reason I will often stop the ACEi when starting an ARB before trying both together if they are both ineffective alone. However I am aware that many people will just add the second drug on top without common issues.

I do gradually increase the ACEi dose over time before calling it ineffective - what doses are you using at the moment?

Important to check blood pressure and urea/creat/electrolytes after any dose increase or new drug in case the drop in glomerular pressure causes significant worsening.

Telmisartan is available as the Veterinary product (Semintra Liquid) or human tablets (20, 40 or 80mg).

Andy

RE: Angiotensin receptor blocker in canine proteinuria

Lucy Fleming — Thu, 08 Dec 2016 17:11:24 GMT

The technical vets at Boehringer might be able to get you a bit more information on Semintra. I spoke to them a while back about it and I think they had one report of it being used successfully in a proteinuric case (literally one dog - they may have more now) that had become refractory to Ace-i.

RE: Angiotensin receptor blocker in canine proteinuria

Stephanie Wellings — Thu, 08 Dec 2016 10:55:59 GMT

He is on benazepril, and the amlodipine was added later because the hypertension was still uncontrolled. The BP did drop a bit further after adding it in, so we continued - I didn't have much experience of amlodipine in dogs either, but for him it has seemed to work.

RE: Angiotensin receptor blocker in canine proteinuria

Martin Atkinson — Thu, 08 Dec 2016 10:30:25 GMT

He's already on an ACEi so I don't see the need to add a similar class of drug. My personal choice of ACEi would be benazepril as it is part excreted via the liver so lessens the load on the kidneys, I have had a bad experience a long time ago with enalapril in a dog with CKD.

Any reason why he's on amlodipine - presumably for the hypertension? AFAIA this is not of much use in dogs and the ACEi should be fine on its own.

I admit I have little experience of treating renal failure in dogs, we just don't see it compared with what seems to be every other old cat. But again AFAIA there is no clear evidence in CKD in cats, other than the company's own (biased?), to suggest that Semintra is better than an ACEi for reducing proteinuria.