?growth on mitral valve leaflet

RE: ?growth on mitral valve leaflet

Martin Atkinson — Wed, 13 Sep 2017 14:08:10 GMT

[quote user="David Mills"] If they're on 10mg/kg frusemide and still not coping their QoL is going to be poor. [/quote]You're the one with the blinkers now.

Their QOL is greatly increased with the switch to Torasemide and it is not prohibitively expensive. This is not something which may or may not work better like Pimobendan v Sildenafil, it is something which does work which is replacing something which has become ineffective.

[quote user="David Mills"]We cannot justify spending money on expensive drugs with no evidence beyond anecdote for a minor improvement in quantity and quality of life. [/quote]I fully understand that but because you are constrained by it don't generalise and suggest that the treatment isn't valid for those who can afford to pay.

[quote user="David Mills"] Following your line of argument, you should have all the most expensive toys and drugs available because you've got "paying clients".[/quote]Not at all, I have very few expensive 'toys' because I can't justify the investment, indeed it is likely an RSPCA hospital has more so that is hypocritical.

The point is that if a client is honestly informed of cost/risk/benefit it is nice to be able to offer an alternative.

If you can't now see my side of the argument then lets just agree to differ rather than mud slinging or pissing as you suggested!!

RE: ?growth on mitral valve leaflet

David Mills — Wed, 13 Sep 2017 13:31:13 GMT

Sigh, it's not a pissing contest.

No, I don't accept anecdote easily because of all the cognitive biases that can affect it, as previously discussed.

Hardly facetious. If they're on 10mg/kg frusemide and still not coping their QoL is going to be poor. CHF is not something to be messed with, and death from it must be one of the worst ways to go, like drowning.

Partly it is to do with justice ethics. We cannot justify spending money on expensive drugs with no evidence beyond anecdote for a minor improvement in quantity and quality of life. It's different when someone is paying (plus markup of course). Your argument is completely illogical. Following your line of argument, you should have all the most expensive toys and drugs available because you've got "paying clients". It's the same reason we don't use apoquel or carry out chemotherapy, you can't offer everything to everyone, and with pimobendan and frusemide available and effective, there is no need. I'm sure you're not so blinkered to not see something so obvious?

RE: ?growth on mitral valve leaflet

Martin Atkinson — Wed, 13 Sep 2017 11:28:43 GMT

[quote user="David Mills"]Again, evidence for its use, or superiority, is lacking. The data sheet makes interesting reading. It's just not something I've ever felt the need to use. If a dog was reaching those levels of frusemide, I would likely consider it euthatal deficient.

[/quote]I know you will never accept my experience but it has worked very well in the limited cases I've used it in. I didn't pluck it out of the air, several highly qualified speakers at CPD events have recommended it.

The adverse reactions list in the BSAVA formulary does make interesting reading but I've not seen any adverse electrolyte/biochemical effects, in fact renal function has improved and it seems very counter-intuitive to warn it can have an adverse effect on cardiac function when its primary use is for furosemide refractory CHF!

It is a case of swings and roundabouts and as said the few cases I've used it on have all benefited: RRR lowered and cough due to pulmonary congestion disappeared when one dog was previously on 10mg/kg Frusemide + spironolactone.

Unlike Sildenafil I'm not tempted to use it as a first line treatment and your suggestion that the patients are better off dead is facetious. Maybe for your charity cases but for paying clients who want to improve the quality of life of their pets it is genuinely useful. As ever your saddle is a bit too high.

RE: ?growth on mitral valve leaflet

David Mills — Wed, 13 Sep 2017 10:49:49 GMT

[quote user="Martin Atkinson"]Generic sildenafil is as cheap as chips, a lot cheaper than pimobendan now - £1.78 for a pack of 8 x 25mg - time to re-think?[/quote]

No. It's use remains anecdotal. And even at that price, for your average CKCS it's still around £10-15/month.

[quote user="Martin Atkinson"]orasemide is useful in cases where the patient is maxing out on Frusemide. Above 8mg/kg the dosing can be tedious and there is little additional benefit. Torasemide re-boots diuresis very effectively with a very manageable dose and it is not prohibitively expensive.[/quote]

Again, evidence for its use, or superiority, is lacking. The data sheet makes interesting reading. It's just not something I've ever felt the need to use. If a dog was reaching those levels of frusemide, I would likely consider it euthatal deficient.

RE: ?growth on mitral valve leaflet

Martin Atkinson — Wed, 13 Sep 2017 09:16:40 GMT

[quote user="David Mills"]

I've no experience of torasemide or sildenafil. The former to me is somewhat emporers new clothes. If the dog is still filling up on maximal doses of fuse identified its time to pts.

[/quote]Torasemide is useful in cases where the patient is maxing out on Frusemide. Above 8mg/kg the dosing can be tedious and there is little additional benefit. Torasemide re-boots diuresis very effectively with a very manageable dose and it is not prohibitively expensive. I have given it to a couple of dogs which have nearly emptied the pharma cupboard and its given them a new lease of life. Its not going to replace giving 1/2 x 20 mg frusemide to a cat with pleural effusion but don't dismiss it.

[quote user="David Mills"]Pimobendan has arteriodilator effects which can be utilised.[/quote]True but even that starts to become less effective in near end stage CHF. I will double the dose which can be beneficial then used to give sildenafil as the final throw but as said its becoming higher on my list.

[quote user="David Mills"] Viagra used to be very expensive but it is off patent - still too much for a charity to be using Esp where the evidence for efficacy is lacking. [/quote]Generic sildenafil is as cheap as chips, a lot cheaper than pimobendan now - £1.78 for a pack of 8 x 25mg - time to re-think?

RE: ?growth on mitral valve leaflet

David Mills — Tue, 12 Sep 2017 20:39:30 GMT

Pimobendan also has anti-cytokine effects which lead to a happy dog effect and is thought to inhibit those that contribute to cardiac cachexia. It seems a remarkable drug.

It actually comes from the human field but has the unfortunate side effect in humans of gyanecomastia in about 25% of patients which is undesirable. There is a similar drug levosimendan which is commonly used.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868185/

I've no experience of torasemide or sildenafil. The former to me is somewhat emporers new clothes. If the dog is still filling up on maximal doses of fuse identified its time to pts.

Pulmonary hypertension probably more prevalent than we realise. I think the diagnosis is fairly straightforward, certainly more so than something like DCM. Pimobendan has arteriodilator effects which can be utilised. Viagra used to be very expensive but it is off patent - still too much for a charity to be using Esp where the evidence for efficacy is lacking.

RE: ?growth on mitral valve leaflet

Sarah Keir — Tue, 12 Sep 2017 17:59:08 GMT

[quote user="Martin Atkinson"]

As a slight aside, I wonder if someone will devise a trial to assess the efficacy of Sildenafil. I am using this much earlier in the course of treatment instead of the last throw of the dice largely on the back of a referred case to the RVC where they used it as first line in pulmonary hypertension.

[/quote]

The problem is diagnosing pulmonary hypertension with general practitioner skill level echo.

RE: ?growth on mitral valve leaflet

Martin Atkinson — Tue, 12 Sep 2017 10:47:48 GMT

[quote user="Thomas Johnson"]

[quote user="Beats"] I can't "see" its effects clearly and obviously in patients I treat with it,[/quote]

I understand your cynicism, but I can remember when Vetmedin was launched and we had a couple of cardiac cases that we were considering euthanasing because they weren't doing well on ACEi and diuretics, and the rapid improvement when they started taking pimobendan was almost unbelievable.

[/quote]Wot he said. I started using Vetmedin as soon as it was launched on a dog that was in near terminal CHF on ACEi, spironolatcone and diuretics I made an appointment for it to go to the RVC and by the time it got there it was 90% better. They sent it back saying they couldn't do any more, at that point even they had not started using it. it lived for another 2 years.

However the benefit of Pimobendan in these cases is of course well documented. The difference is that the trials give more confidence in using it as first line rather than second or third. I didn't need any trial with a dodgy acronym to convince me of that.

RE: ?growth on mitral valve leaflet

Thomas Johnson — Tue, 12 Sep 2017 09:40:43 GMT

[quote user="Beats"] I can't "see" its effects clearly and obviously in patients I treat with it,[/quote]

RE: ?growth on mitral valve leaflet

Beats — Mon, 11 Sep 2017 22:05:59 GMT

[quote user="David Mills"]Oh you cynic.[/quote] Too true.

I'll take your personal recommendation happily though.

I've always been a bit cynical regarding pimobendan, primarily because I've never heard anything bad about it, it appears (in my limited experience) to be wholly benign when given for years to patients that didn't clearly need it (a reverse sneezing dog comes to mind), even after years of administration it can apparently be abruptly stopped with no obvious detrimental rebound effects, I can't "see" its effects clearly and obviously in patients I treat with it, it is a wonder-drug for all domestic species (but no drug in its class has performed well in large-scale human trials despite numerous attempts as I understand it?). Part of me is cynical and part of me thinks it should be in the drinking water.

I do appreciate the tremendous effort in doing these trials however, so kudos to all those involved.

RE: ?growth on mitral valve leaflet

David Mills — Mon, 11 Sep 2017 20:52:13 GMT

[quote user="Beats"]

[quote user="Martin Atkinson"]OK so: QUEST showed the benefit of Pimobendan over an ACEi; PROTECT showed the benefit of pre-emptive Pimobendan in Dobies with DCM and EPIC showed the advantage of pre-emptive treatment in dogs with MVD. [/quote]

Q: Have Boerhinger-Ingelheim ever funded a pimobendan study that has NOT shown a benefit? If not, that is truly epic.

(being cardio-ignorant and internet-lazy, I'm assuming they funded these studies, but haven't actually checked; I have no idea if this is the complete list)

[/quote]

Oh you cynic. One of the principal investigators is one of my PhD supervisors and I can tell you they're some of the most objective and best designed studies in veterinary Medicine and Boehringer don't see the results until they're done.

EPIC was stopped at interim analysis because the results were so clear.

RE: ?growth on mitral valve leaflet

Beats — Mon, 11 Sep 2017 19:25:33 GMT

Q: Have Boerhinger-Ingelheim ever funded a pimobendan study that has NOT shown a benefit? If not, that is truly epic.

(being cardio-ignorant and internet-lazy, I'm assuming they funded these studies, but haven't actually checked; I have no idea if this is the complete list)

RE: ?growth on mitral valve leaflet

Neil Wheadon — Mon, 11 Sep 2017 15:47:41 GMT

[quote user="Martin Atkinson"][quote user="David Mills"]Can you remember your own name?[/quote]Sometimes I have a problem but I don't have an acronym to help me![/quote]

That's a thread in itself

Neil

RE: ?growth on mitral valve leaflet

Martin Atkinson — Mon, 11 Sep 2017 15:39:24 GMT

[quote user="David Mills"]Can you remember your own name?[/quote]Sometimes I have a problem but I don't have an acronym to help me!

[quote user="David Mills"](I think you mean PROTECT old fruit)[/quote]OK so: QUEST showed the benefit of Pimobendan over an ACEi; PROTECT showed the benefit of pre-emptive Pimobendan in Dobies with DCM and EPIC showed the advantage of pre-emptive treatment in dogs with MVD.

Have I got it right this time maestro?

RE: ?growth on mitral valve leaflet

David Mills — Mon, 11 Sep 2017 13:28:31 GMT

[quote user="Martin Atkinson"]I got my trial acronyms mixed up and it was QUEST which showed the benefit of Pimobendan over an ACEi in Dobermans with DCM[/quote]

Was it?

https://www.ncbi.nlm.nih.gov/pubmed/18638016

Can you remember your own name?

(I think you mean PROTECT old fruit)

RE: ?growth on mitral valve leaflet

Martin Atkinson — Mon, 11 Sep 2017 10:51:42 GMT

[quote user="David Mills"]Weird response. [/quote]Weird is not quite the word I'd have used - technically incorrect maybe: I got my trial acronyms mixed up and it was QUEST which showed the benefit of Pimobendan over an ACEi in Dobermans with DCM; EPIC showed the advantage of pre-emptive treatment in dogs with MVD. I was the first vet other than those involved in the trial who knew the results of the EPIC trial as I as told 5 minutes after the results were officially released in 2015 by Mark Patterson on SPVS Snowscene. Now that is what you call up to the minute CPD! It took another year for the results to be published.

RE: ?growth on mitral valve leaflet

Bill Nolan — Sun, 10 Sep 2017 14:31:48 GMT

[quote user="Emily Rainbow"]I would also have neoplasia on the list too, especially as it's a boxer![/quote]

Although the mumur was present since it was a pup.

RE: ?growth on mitral valve leaflet

Emily Rainbow — Sat, 09 Sep 2017 19:04:45 GMT

I would also have neoplasia on the list too, especially as it's a boxer!

RE: ?growth on mitral valve leaflet

Charlotte Marshall — Sat, 09 Sep 2017 11:45:43 GMT

I took a proBNP at the time I'm just awaiting results.

RE: ?growth on mitral valve leaflet

David Mills — Sat, 09 Sep 2017 01:58:00 GMT

[quote user="Martin Atkinson"]

I am a huge fan of preemptive treatment in cardiac disease and the EPIC trial has only served to confirm my feelings on that. However it applies more to dogs with cardiomyopathy not mitral valve disease and if the dog is not showing any signs of cardiac failure due to that then I cannot see it would be of benefit until it needs to be part of management of CHF. An NT-proBNP may give you a bit more of an idea about that if you're not happy with your echocardiography.

I defer to anyone who has a greater knowledge/experience.

[/quote]

???

http://www.results.epictrial.com

Weird response.

Anyway. It's not endocarditis because the dog isn't ill. Concerning that you can spot a lesion on mitral valve but couldn't measure ratio? It could have been an orientation issue.

Although not unheard of in boxers, mvdd would not be top of the list. Discount probnp and either sedate and scan at ease or refer.

RE: ?growth on mitral valve leaflet

Martin Atkinson — Fri, 08 Sep 2017 17:31:39 GMT

I defer to anyone who has a greater knowledge/experience.