Canine Congestive Heart Failure

Re: Canine Congestive Heart Failure

Don Rutherford — Thu, 14 Apr 2011 13:59:24 GMT

Update, as promised. On Vetmedin and Frusemide there was a slight improvement for a few days, then a rapid deterioration.

With much heart-searching the owner decided on PTS.

Re: Canine Congestive Heart Failure

David Mills — Tue, 12 Apr 2011 22:01:03 GMT

Classic category mistake.

Your formula: dexamethasone + drug x (which happens to be licensed for CHF)

Mine: dexamethasone + specific condition

For yours to work each drug would have to be trialled alongside every possible co-administration in order for it to be omitted/included in the contraindications. They are obviously not.

I do not argue that dexamethasone has a potentiating effect on frusemide; but what you quote does not in any way justify its use in CHF. Additionally, it is no more efficacious, or quicker, than frusemide + a thiazide +/- spironolactone can achieve or frusemide alone at the correct frequency and at decent doses; I am intrigued by use of 'better'. Dexamethasone, along with all other corticosteroids, promotes sodium retention, thirst, and volume expansion/maintenance - exactly that which we are trying to avoid - and has a far longer residual effect (even the short acting formulation upto 10 days) with associated side-effects than any diuretic. A recent human study into its effects in CHF patients was suspended.

So, you can search all the CHF-licensed product licences: more efficiently, see these:

http://www.noahcompendium.co.uk/Eurovet_Animal_Health_Ltd/Rapidexon/-54189.html

http://www.noahcompendium.co.uk/Intervet_Schering-Plough/Dexadreson__Solution_for_injection/-28810.html

Re: Canine Congestive Heart Failure

Michael Woodhouse — Tue, 12 Apr 2011 20:39:22 GMT

[quote user="David Mills"]Corticosteroids are directly contraindicated in any CHF (in all the data sheets)[/quote]

From the Dimazon data sheet:

Clinical experience with dogs indicates that improved results can frequently be achieved by supplementary administration of corticosteroids.

I have just re-read the Vetmedin data sheet and can find no steroid contraindication.

Nor with the Enacard data sheet - no mention of contraindication (although potassium sparing diuretics contraindicated)

Getting bored of reading data sheets now. Not advocating prolonged steroid use in these cases, but some dexamethazone with the initial frusemide is indicated on the data sheet for the frusemide and seems to shift fluid better [in my experience] in cases of pulmonary odema or ascites than a diuretic alone.

Re: Canine Congestive Heart Failure

David Mills — Tue, 12 Apr 2011 20:01:50 GMT

Possibly not covered but surely primary heart disease classification is fairly important? No indications re size of dog (unless the dog wrote the post himself) but both MMVD or DCM or both together would make vetmedin a far better choice than ACE-i if a choice needed to be made - the evidence is out there in striking detail, so vets really should be using it. PDE inhibitors also have a remarkable 'happy dog' effect. Of course if it was something weird and wonderful like a HCM or RCM (i.e. not a systolic failure) then ACEi. Fruesmide is the cornerstone of any CHF therapy regardless of cause.

Corticosteroids are directly contraindicated in any CHF (in all the data sheets) unless in emergency situations such as anaphylaxis - you would have a hard time explaining their use at a hearing for use in CHF therapeutics.

Methylxanthines only work to have any therapeutic effects on the heart at something like 10-20 times their stated dosages. Their 'usefulness' in CHF likely to be related to their mild diuretic effect, and possibly in cough reduction.

For antihypertensives, ACEi 1st choice, followed by amlodopine if response not great.

Re: Canine Congestive Heart Failure

Mark Hedberg — Sat, 09 Apr 2011 08:08:09 GMT

[quote user="labrador"]

An abundance of suggestions - much appreciated.

I am trying the most favoured, Frusemide +Vetidrin. Will decide in a week whether to change regimen. And will post result.

This is a much-loved old dog owned by a (non-vet.) colleague so worth effort.

P.S. Told repeatedly by V.D.S. that Millophylline discontinued a long time ago. Yet when I contacted Dechra I was told there was no problem with supply. Very confusing

[/quote]

Tablets are gone, injection is still widely available.

Re: Canine Congestive Heart Failure

CatherineThomas — Sat, 09 Apr 2011 07:18:48 GMT

[quote user="Stephen Courtney"]

I thought steroids were a bad thing to give in the face of congestive heart failure...not that I've never used them when i felt they were needed...

[/quote]

I agree. I avoid steroids if at all possible if there is any heart disease.

Re: Canine Congestive Heart Failure

Stephen Courtney — Fri, 08 Apr 2011 21:25:23 GMT

I thought steroids were a bad thing to give in the face of congestive heart failure...not that I've never used them when i felt they were needed...

Certainly in cats i worry about the effect of roids on a cardiomyopathy.

Re: Canine Congestive Heart Failure

Don Rutherford — Fri, 08 Apr 2011 15:39:51 GMT

An abundance of suggestions - much appreciated.

I am trying the most favoured, Frusemide +Vetidrin. Will decide in a week whether to change regimen. And will post result.

This is a much-loved old dog owned by a (non-vet.) colleague so worth effort.

P.S. Told repeatedly by V.D.S. that Millophylline discontinued a long time ago. Yet when I contacted Dechra I was told there was no problem with supply. Very confusing

Re: Canine Congestive Heart Failure

Michael Woodhouse — Fri, 08 Apr 2011 15:37:45 GMT

If money is an issue steroids potentiate the diuretic effect of the frusemide. I will quite often give some Dex with he frusemide if they have much fluid to shift.

Re: Canine Congestive Heart Failure

Julian Earl — Fri, 08 Apr 2011 14:31:10 GMT

[quote user="robloxley"]

[quote user="Stephen Courtney"]I almost always add in spironolactone ( which should be given with food as it is fat soluble) to reduce myocardial fibrosis, and reduce hypokalaemia secondary to frusemide use.[/quote]

Certainly I feel I'm using spironolactone more as an aldosterone antagonist than primarily as a diuretic. Moduretic seems to be a more effective second line diuretic when they're on top whack frus.

[quote user="Laurence Webb"]With unlimited funds I'd use Frusemide/Vetmedin/ACE inhibitor/Spironolactone then other drugs as required. In most cases there is a cost compromise so I'd use them in that order of preference.[/quote]

IMHO again, if cost is an issue I find that by reducing the doses of the expensive drugs to the low end of the range and still using a combination of frus/spironolac/pimoben and benazepril, they seem to do better than say just using frusemide and top-end dose vetmedin. It would be nice to have some evidence to back this up however :)

[/quote]

Or as Mark Patteson said at some CPD a couple of years ago, (and I paraphrase), "Frusemide/Vetmedin/ACE inhibitor/Spironolactone/fish oils/digoxin and codeine as cough suppressant. If cost is an issue for all of these, tell them that at least they won't be giving them for long."

Sorry, but it was an unforgettable comment.

Re: Canine Congestive Heart Failure

Martin Atkinson — Fri, 08 Apr 2011 13:12:05 GMT

[quote user="alex gough"]

It's fairly well-established that if it's a choice between ACEi or pimobendan, then you should use pimobendan, after the QUEST trial. Interestingly we were discussing the ACVIM consensus on CHF at the evidence based medicine stream at BSAVA, and the consensus is to use pimobendan and ACEi, even though best evidence currently is just for pimobendan.

A summary of the ACVIM consensus statement is here

Alex

[/quote]

I fully agree but Vetmedin is a lot more expensive than most ACEis but it would be my first choice with no cost constaints and I believe is of use in pre-emptive treatment before onset of CHF in all stage B cases.

Re: Canine Congestive Heart Failure

Alex Gough — Fri, 08 Apr 2011 08:49:19 GMT

A summary of the ACVIM consensus statement is here

Alex

Re: Canine Congestive Heart Failure

Rob Loxley — Fri, 08 Apr 2011 00:51:23 GMT

[quote user="Stephen Courtney"]I am currently looking for cases to try Cardiguard on[/quote]

IMHO there's a lot better proven drugs to spend money on for a CHF dog, though I'm sure it'll do no harm and their coat will be glossy.

Certainly I feel I'm using spironolactone more as an aldosterone antagonist than primarily as a diuretic. Moduretic seems to be a more effective second line diuretic when they're on top whack frus.

[quote user="Martin Atkinson"]I'm not convinced thats anything other than a selling spiel for Prilactone[/quote]

With the usual caveats on the differences in human and canine heart disease, the benefit of spironolactone in the RALES CHF study is impressive, particularly at doses of <0.5mg/kg/day.

[quote user="Catherine Williams"]Have to agree, far more likely to start off with an ACE-inhibitor as a first line or Vetmedin if I'm worried about it.[/quote]

So if you are choosing between ACEi or pimobendan (plus frus) you'd choose the ACEi?

Re: Canine Congestive Heart Failure

Stephen Courtney — Thu, 07 Apr 2011 21:24:52 GMT

My favourite is vetmedin and frusemide. I almost always add in spironolactone ( which should be given with food as it is fat soluble) to reduce myocardial fibrosis, and reduce hypokalaemia secondary to frusemide use. I will give ACE inhibitors with vetmedin in severe cases, and there is room to vary doses considerably. you should always recheck a few days after altering doses.

I am currently looking for cases to try Cardiguard on, it is a concentrated omega 3 fatty acid supplement. So far the 2 cases I have used it on have been equivocal - one was deceased in a week due to a sudden death scenario whcih i was NOT expecting, and the other is doing fine.

Millophylline is a bronchodilator and has inotropic effects. I would not use it for anything other than acute situations with dyspnoea and a sense of desperation, when i will use the injectable. If I need an oral med to help here, i usually use vivitonin, and occasionally corvental.

I don't find any use for millophylline otherwise, haven't used the red tablets for years!

Re: Canine Congestive Heart Failure

Gillian Mostyn — Thu, 07 Apr 2011 21:20:58 GMT

[quote user="Martin Atkinson"]Why on earth in this day and age would anyone want to use Millophyline for heart failure even if it was still available?[/quote]

A little harsh - they were asking for advice afterall!

Re: Canine Congestive Heart Failure

Mark Hedberg — Thu, 07 Apr 2011 21:13:25 GMT

I've actually found spironolactone to be quite good, but that's just my anecdotal evidence. I would suggest getting blood pressure measurements before giving an ACE inhibitor (just in case) but that's mainly because I get paranoid about renal perfusion. Vetmedin is lovely stuff; if cost is truly an issue then fruse/vivitonin is a decent compromise, but I actually feel millophylline worked better than propentophylline. I've used corvental in two heart cases where vetmedin caused vomiting and it seems to work quite well.

Anecdotal again, but that's the internet for you.

Re: Canine Congestive Heart Failure

Laurence Webb — Thu, 07 Apr 2011 20:32:41 GMT

With unlimited funds I'd use Frusemide/Vetmedin/ACE inhibitor/Spironolactone then other drugs as required. In most cases there is a cost compromise so I'd use them in that order of preference. If you want to use a methylxanthine then Corvental is the one I normally reach for, but Vivitonin would be another option.

Re: Canine Congestive Heart Failure

Martin Atkinson — Thu, 07 Apr 2011 18:52:48 GMT

Why on earth in this day and age would anyone want to use Millophyline for heart failure even if it was still available? I would use an ACEi (Fortekor probably) with Pimobendan and Frusemide. If funds are limited just the ACEi & frusemide. Add in spironolactone if frusemide on its own is not enough - some advocate its use to reduce myocardial fibrosis and as an additional aldosterone antagonist as a starter drug but I'm not convinced thats anything other than a selling spiel for Prilactone. Hypertension is not a regular feature of CHF in dogs IME but the ACEi should help. ECG regularly to look for arrythmias and may then need an anti-arrythmogenic drug but thats another topic.

Re: Canine Congestive Heart Failure

Alex Gough — Thu, 07 Apr 2011 17:15:27 GMT

I agree with James. Starting frusemide without adding an ACE inhibitor or Vetmedin stimulates the renin-angiotensin aldosterone axis, which is a bad thing in CHF.

Alex

Re: Canine Congestive Heart Failure

James Allsop — Thu, 07 Apr 2011 16:31:46 GMT

I would start vetmedin/ACEi + frus initially (preference for vetmedin these days) - only tend to use bronchodilators if the cough remains a problem, known bronchial disease. Sometimes if i get an case of coughing that i think may be CHF/bronchitis but the owners wont pay for investigation i start on corvental/vivitonin to see if responds and help differentiate between the two differentials.

Re: Canine Congestive Heart Failure

Catherine Williams — Thu, 07 Apr 2011 16:22:00 GMT

Have to agree, far more likely to start off with an ACE-inhibitor as a first line or Vetmedin if I'm worried about it. Both seem to work nicely in my hands.

Re: Canine Congestive Heart Failure

Dagmar Steele — Thu, 07 Apr 2011 16:08:51 GMT

why not choose something as an ACE-Inhibitor?