VMD statement on Calmex

Re: VMD statement on Calmex

Evelyn Barbour-Hill — Mon, 23 Jul 2012 19:39:07 GMT

[quote user="Rajat"]Findings Evaluation of the therapeutic strategies chosen for these hypothetical cases of HCM suggests that cardiologists or clinicians with a strong interest in cardiology often prescribe treatments knowing that little documented evidence supports their decisions.[/quote]

I love that.

Re: VMD statement on Calmex

Rajat — Mon, 23 Jul 2012 13:03:34 GMT

[quote user="David Mills"]Sadly the best we have, though. I consider it better than any retrospective analysis, but that's opinion.[/quote]

I guess we will have to agree to disagree because I think retrospective published analysis is better in this situation. this was never peer reviewed and never published, which should hint at something! I doubt many findings here would achieve statistical significance either (but I am no statistician and haven't analysed the data myself - if even available..)

[quote user="David Mills"]Asymptomatic - no evidence they work apart from abolishing SAM [/quote]

Why would we do this anyways, unless symptomatic...Payne study showed remarkable longevity in these cats (w/DLVOTO) and I personally (and other caridos I know) do not use it unless symptomatic for weakness syncope etc or it is suspected but not overtly manifested (eg lethargy)

[quote user="David Mills"]Fox abstract shows negative impact on survival[/quote]

You mean the abstract ? Fair enough tho - I don't tend to use it in HCM cats and especially not when in current CHF anyways without a good reason -tachycardia or as outlined above.

Sure you are aware while the negative chronotropy and inotropy of beta blockade can theoretically be beneficial, these drugs also are negative luisotropes which is th eopposite effect we want on the most significant aspect of this disease i.e. diastolic function. Which is why I am not fond of them un-neccessarily.

[quote user="David Mills"]They also have, when started, negative effects on systolic function (present in a lot of cats with CHF though diastolic predominates[/quote]

In the advanced stages yes, but early-mid HCM and CHF diastolic dysfunction is the main problem and not systolic function (most are hyperdynamic with FS>50%) so I think exacerbation of CHF cocurs due to beta blockade in some cases, but not because of reduced systolic function. Later on, in advanced cases, IME, its both which are exacerbated.

[quote user="David Mills"] I think the consensus is that -ve chronotropy in cats with CHF is a good thing though,[/quote]

I would love a consensus statement on feline HCM from ACVIM/ECVIM like they did for DMVD - I don't believe there is a general agreement- and like I said many cardios (that I kniow of)dont use beta blockade routinely - but I think a negative chronotrope which has no effect on systolic and diastolic function would be quite interesting, and hence I was excited about Ivabradine.

[quote user="David Mills"]although I wonder how much more in HCM the LV is distendable with increased time. [/quote]

If I understand correctly, the LV becomes less distendable as infacrtion and fibrosis replaces myocardium and diastoluc function deteriorates- maybe I misunderstood your comment.

[quote user="David Mills"]Having said that, I do have high hopes for beta blockers largely due to their overwhelming efficacy in humans, and it would be interesting to see how the 3rd generational ones e.g. carvedilol with non-selective mixed effects on adrenergic receptors would be tolerated in cats in this setting[/quote]

Oyama is still trialling/using these in DCM and MMVD, still seem to have no luck, (am sure you read the paper )and the slow up-titration you mentioned is a major factor due to shorter lives of pets. Raises an interesting point tho - do you titrate up Beta blockade in cats like they discuss in dogs with Carvedilol..? I don't and haven't heard of this in cats before- maybe because I am using it in only select cases of symptomatic DLVOTO rather than trying to treat the majorioty of HCM cases with it like has been discussed previously. henc eI don't find them a faff in this regard, but if you have any literature pointing towards the need to titrate up in cats I'd be grateful for the link.

[quote user="David Mills"]amiodarone[/quote]

When would you use this rather than atenolol in cats (unless for an un-responsive arrhythmia)?

[quote user="David Mills"]What are these 'more problems', clinically speaking (i.e. endpoint affecting as opposed to measurable/experimental/theoretical)? Speaking about diltiazem particularly. I agree they're a faff with TID dosing and the ER form isn't well tolerated in cats but they do achieve -ve chronotropy +/- increased coronary BF which theoretically we are trying to achieve.[/quote]

Problems are- side effects, at dose rates and dose intervals which achieve therapeutic plasma levels are common with TID dosing and the XR product is difficult to dose and the 60mg (from 240mg XR) causes severe V+. In the face of no evidence (AFAIAC - fox study doesnt cut it) and the potential cost to owners and giving a pill three times daily which can cause severe GI s/e, and also tachycardia everytime it is pilled-= I'd rather not. Maybe worth checking with a specialist or two and see how many still recommend using it!

[quote user="David Mills"]I agree it's unlikely ACEi are unlikely to do any harm, but I'm distinctly unconvinced they do any good - bit like homeopathy really.[/quote]

I think bit better than homeopathy in CHF, I doubt all the RCVS registered carido specialists using it in CHF equate it to homeopathy!But, evidence in cats is lacking big time for our interventions so I don't think we can anything definitive about anything...other than frusemide appears to keep pulmonary oedema at bay!

Abstract

Practical relevance Feline hypertrophic cardiomyopathy (HCM) is the most common cardiac disease of cats. Treatment of HCM is usually directed at controlling signs of congestive heart failure (CHF), preventing occurrence or recurrence of systemic thromboembolism or delaying/preventing/reversing progression of subclinical disease.

Study objective and design Despite the laudable goals of therapy, however, little objective evidence supporting therapeutic decisions has been published. We, therefore, hypothesized that cardiologists base their treatment strategies on information other than published clinically relevant science. To gain insight into therapeutic decisions that cardiologists and clinicians with an interest in cardiology (n = 99) make for cats with HCM, and on what information they base these decisions, we presented participants with, and asked them to select therapy for, 12 hypothetical scenarios of HCM (± CHF). Responses and justifications for treatment choices were compiled and compared with the results of a comprehensive literature search for published information about treatment of feline HCM.

Findings Evaluation of the therapeutic strategies chosen for these hypothetical cases of HCM suggests that cardiologists or clinicians with a strong interest in cardiology often prescribe treatments knowing that little documented evidence supports their decisions.

Right so who's up for a prospective study of ACE-iin cats with CHF?!

Best

Raj

Re: VMD statement on Calmex

David Mills — Fri, 20 Jul 2012 15:28:28 GMT

[quote user="Rajat"]

exactly- an abstract presented many moons ago never written up tho still talked about and referred to as if carries a lot of weight...!

[/quote]

Sadly the best we have, though. I consider it better than any retrospective analysis, but that's opinion.

[quote user="Rajat"]

[quote user="David Mills"] Greater efficacy than placebo was wrong[/quote]

sorry what does this mean?

[/quote]

Reference to my previous incorrect statement about diltiazem showing improvement cf frusemide in the Fox abstract.

[quote user="Rajat"]

[quote user="David Mills"]especially with the inherent problems with beta-blockers. [/quote]

which are what exactly..?

[/quote]

Depends what you're talking about really. Asymptomatic - no evidence they work apart from abolishing SAM - though according to the Rush study this is associated with longer survival times anyway - so should we be abolishing it/does it improve MST or time to CHF? Syptomatic - no evidence efficacy and Fox abstract shows negative impact on survival. They are fiddly things, titrating to effect, and it may be that cats with CHF die before they can be titrated up sufficiently. They also have, when started, negative effects on systolic function (present in a lot of cats with CHF though diastolic predominates) and may lead to acute exacerbation of CHF. I think the consensus is that -ve chronotropy in cats with CHF is a good thing though, although I wonder how much more in HCM the LV is distendable with increased time. Having said that, I do have high hopes for beta blockers largely due to their overwhelming efficacy in humans, and it would be interesting to see how the 3rd generational ones e.g. carvedilol with non-selective mixed effects on adrenergic receptors would be tolerated in cats in this setting, or even amiodarone of which I am a big fan in dogs. I think unfortunately this heterogenous group of compounds get lumped together with atenolol.

[quote user="Rajat"]

I agree MArtin things go around in circles sometimes, the current 'vogue' may be not to use hypercard for HCM cats I bet it doesnt come back into fashion, there are many more problems with Ca channel blockers in cats than there are with beta blockers (tho maybe DM will shed some light on his opinion/info on this).

[/quote]

What are these 'more problems', clinically speaking (i.e. endpoint affecting as opposed to measurable/experimental/theoretical)? Speaking about diltiazem particularly. I agree they're a faff with TID dosing and the ER form isn't well tolerated in cats but they do achieve -ve chronotropy +/- increased coronary BF which theoretically we are trying to achieve. They are also of equal evidence base currently to ACEi. I agree it's unlikely ACEi are unlikely to do any harm, but I'm distinctly unconvinced they do any good - bit like homeopathy really.

Re: VMD statement on Calmex

Martin Atkinson — Fri, 20 Jul 2012 12:23:32 GMT

[quote user="Rajat"]I agree MArtin things go around in circles sometimes, the current 'vogue' may be not to use hypercard for HCM cats I bet it doesnt come back into fashion, there are many more problems with Ca channel blockers in cats than there are with beta blockers (tho maybe DM will shed some light on his opinion/info on this).[/quote] True, I have boxes of Hypercard going (or gone) out of date on my shelves and I reach for a Beta blocker now for arrythmias notably atenolol. There is some danger using diltazem if you get your diagnosis wrong at least with ACEi it shouldn't do any harm.

Re: VMD statement on Calmex

Rajat — Fri, 20 Jul 2012 12:02:59 GMT

[quote user="David Mills"]The Fox extract[/quote]

exactly- an abstract presented many moons ago never written up tho still talked about and referred to as if carries a lot of weight...!

[quote user="David Mills"] Greater efficacy than placebo was wrong[/quote]

sorry what does this mean?

[quote user="David Mills"]especially with the inherent problems with beta-blockers. [/quote]

which are what exactly..?

Re: VMD statement on Calmex

Martin Atkinson — Wed, 18 Jul 2012 18:30:52 GMT

I recall feeling very smug putting cats on ACEi for HCM many years ago before many others did, then I referred a cat to Bristol and they put it on Hypercard because they reckoned it was better. The next fashion was to put them on both and then finally it was decided that they both worked as well individually so i was right all along. As suggested it may be useful for a tachycardia but most owners cant/don't want to pill 3 times a day. I've tried crushing and suspending the human longer acting tablets in water for the owner to syringe but quite honestly have found it now advantage over benazepril and now pimobendan.

Re: VMD statement on Calmex

David Mills — Wed, 18 Jul 2012 10:23:17 GMT

[quote user="Rajat"]

Which study are you referring to showing equal potency to ace inhibitors?

[/quote]

The Fox extract shows no statistical difference between dllt/frus, enal/frus, frus. Greater efficacy than placebo was wrong, though some older papers show tantalising evidence it may work, not subsequently followed up. For the right tachycardic cat still worth considering however especially with the inherent problems with beta-blockers.

Re: VMD statement on Calmex

Rajat — Wed, 18 Jul 2012 03:09:55 GMT

[quote user="David Mills"]

[quote user="Bob Russell"]

How many are still using Hypercard?

[/quote]

Not sure the reason for this inclusion. Diltiazem is a fantastic drug for rate control in AF, and can be very useful in cats with CHF/HCM, prolonging life versus placebo and showing some comparable action to ACEis. A lot of cardiologists still use the drug, actually, although the (unlicensed) sustained release form is easier to administer.

[/quote]

Beg to disagree, while many cardiologists do use it for rate control in AF (alongside dig in dogs) the vast majority do not use it in cats as far as I am aware ..They have short half lives in cats requiring TID-QID dosing, and higher incidence of side effects. Which study are you referring to showing equal potency to ace inhibitors?

Ivabradine in cats has been trialled recently David did you see the papers, I bet this drug shows promise in the coming years

Bob by all means book the CPD but you were right the first time - I haven't used hypercard in many years in a cat (did it once, few months out, - tho it was in the cardio notes as the licensed medication, and newbie me felt I had to do something for the cat with a murmur...!)

Re: VMD statement on Calmex

Bob Russell — Fri, 11 Nov 2011 09:50:32 GMT

[quote user="David Mills"]

[quote user="Bob Russell"]

How many are still using Hypercard?

[/quote]

I stand corrected. I did some CPD that indicated that it was contra-indicated now! I will do some more CPD to correct my deficiencies!

Re: VMD statement on Calmex

David Mills — Thu, 10 Nov 2011 20:24:38 GMT

[quote user="Bob Russell"]

How many are still using Hypercard?

[/quote]

Re: VMD statement on Calmex

Evelyn Barbour-Hill — Thu, 10 Nov 2011 20:13:16 GMT

[quote user="Arlo Guthrie"]

[quote user="Evelyn Barbour-Hill"][quote user="Arlo Guthrie"]I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?[/quote]

Because to all intents and purposes it does so claim, but avoids making the claim in so many words, thus dodging the legislation. [/quote]

Yes, I appreciate that. My point is that it really should not be possible to dodge the legislation by making the claim in so many words.

I think that if a product is even implied to treat, cure or prevent, it should be authorised.

[/quote]

You have, indeed, reached the nub or crux of the matter.

Re: VMD statement on Calmex

Bob Russell — Thu, 10 Nov 2011 13:41:04 GMT

[quote user="robloxley"]

[quote user="Arlo Guthrie"]

That also seems a bit odd. I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?

[/quote]

Plenty of people buy glucosamine for themselves and their pets (added to most of the other products in Holland and Barratt etc. al.) because they feel it helps.

Essentially the makers get as close to alluding to medicinal claims without crossing the line that would need to get them licensed/tested etc. (and the burdens of proof and cost therein)

[/quote]

Unfortunately many of these products are labelled in such an in your face way that it is difficult or impossible not to believe they are medicines and tested as such!

Just go and check the nutraceuticals you have on your shelf or as another (almost random) example naf-uk.com! This is what the final consumer sees and believe to be tested and effective. A horse on a good balanced diet is unlikely to be deficient in any of these ingredients. A human getting a balanced diet is unlikely to be deficient. These supplements, with their pseudo-medical claims will not correct a bad diet.

Owners and vets need to be able to sort out the wheat from the chaff. As vets we need to be confident that anything we recommend has at least some science and evidence behind it.

As you may have worked out I am not a great seller of 'snake oil' and before I am questioned on my choices of medicines, I fully accept that they are not perfect either and review and update my prescribing habits accordingly. How many are still using Hypercard?

Re: VMD statement on Calmex

Arlo Guthrie — Thu, 10 Nov 2011 13:27:32 GMT

[quote user="Evelyn Barbour-Hill"][quote user="Arlo Guthrie"]I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?[/quote]

Because to all intents and purposes it does so claim, but avoids making the claim in so many words, thus dodging the legislation. [/quote]

Yes, I appreciate that. My point is that it really should not be possible to dodge the legislation by making the claim in so many words.

I think that if a product is even implied to treat, cure or prevent, it should be authorised.

Re: VMD statement on Calmex

Rob Loxley — Thu, 10 Nov 2011 12:28:50 GMT

[quote user="Arlo Guthrie"]

That also seems a bit odd. I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?

[/quote]

Plenty of people buy glucosamine for themselves and their pets (added to most of the other products in Holland and Barratt etc. al.) because they feel it helps.

Essentially the makers get as close to alluding to medicinal claims without crossing the line that would need to get them licensed/tested etc. (and the burdens of proof and cost therein)

Re: VMD statement on Calmex

Bob Russell — Thu, 10 Nov 2011 10:53:17 GMT

Whist not trying to single out VetPlus (many companies are making similar products) there are clear medical claims. Cystaid for example claims 'to help maintain the protective glycosaminoglycan layer in the bladder of the cat' as one example. This strikes me as a medical claim so this, surly, should be licensed as a medicine.

One reason for us having to follow cascade in small animals is to ensure proper income for pharmaceutical companies to develop, license and manufacture therapeutic products.

In our local saddlers there is shelf after shelf of 'medicines' ,all unlicensed, promising the unwary improved mobility, calmness, activity, improved immune systems, in fact pretty much everything. All at a great cost but impressive packaging suggests well tested products, manufactured to pharmaceutical standards. I have often wondered why owners don't expect to see these piled high at the local vets if they are that good!

I cannot see anyone taking on this multi-million (billion?) pound/dollar industry nor the shelves of patent snake oil preparations at the local pet shop.

Re: VMD statement on Calmex

Evelyn Barbour-Hill — Wed, 09 Nov 2011 21:28:54 GMT

[quote user="Arlo Guthrie"]I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?[/quote]

Because to all intents and purposes it does so claim, but avoids making the claim in so many words, thus dodging the legislation.

Re: VMD statement on Calmex

Arlo Guthrie — Wed, 09 Nov 2011 18:55:16 GMT

[quote user="Martin Atkinson"] PS just received this statement from Vetplus

www.vetsurgeon.org/.../6254.Vetlpus-Calmex-statement.pdf[/quote]

VERY surprised to read that.

But in the course of looking into this, I've been quite surprised at the lack of clarity in the regulations:

The VMD classify veterinary medicines as either medicinal by function, or medicinal by presentation.

Medicinal by function is defined as follows:

A product is considered medicinal by function if it possesses properties for treating or preventing disease in animals or if it may be administered to animals with a view to restoring, correcting or modifying a physiological function.

That description could be applied to water, surely?

But rather more to the point, if a product does NOT have properties for treating or preventing disease in animals, that would mean it doesn't work. In which case, what is it doing being sold in the first place??!!

By contrast, and regardless of efficacy, if a company claims a product 'treats, cures or prevents', it becomes a medicine by presentation, in which case it needs a marketing authorisation.

That also seems a bit odd. I mean, if the company does NOT claim that it 'treats, cures or prevents', then why would I buy it?

Maybe I'm missing something.

Re: VMD statement on Calmex

Martin Atkinson — Wed, 09 Nov 2011 18:05:06 GMT

[quote user="Robin Grimmer"]

I visited Fiji in '98 and I also tried some Kava (also known as Yaquna sp?). It was a brown liquid and tasted foul, just like soil!

[/quote]

Could be why of the the few people I've given Calmex, those who put it in their pet's food reported them not eating it.

And like Arlo I don't know why I got one star for saying you can buy Kava on the internet if you want to.

PS just received this statement from Vetplus

www.vetsurgeon.org/.../6254.Vetlpus-Calmex-statement.pdf

Re: VMD statement on Calmex

Arlo Guthrie — Wed, 09 Nov 2011 17:52:44 GMT

[quote user="Bob Russell"]Lots of one stars - Ouch![/quote]

Yes, and I can't figure out why. All the one starred posts in this thread have added something useful or interesting ...

Re: VMD statement on Calmex

Bob Russell — Wed, 09 Nov 2011 17:44:44 GMT

Lots of one stars - Ouch!

Re: VMD statement on Calmex

Evelyn Barbour-Hill — Wed, 09 Nov 2011 17:42:28 GMT

[quote user="Sarah Keir"]The locals drink it regularly but they don't really drink alcohol or smoke and their life expectance is lower than in the west.[/quote]

Post hoc ergo propter hoc?

Sorry.

Re: VMD statement on Calmex

Sarah Keir — Wed, 09 Nov 2011 17:20:50 GMT

I had Kava a few years ago on Vanuatu. Tasted horrible - the tradition is to drink it in the dark looking away from the circle of people (so they can't see the face you are pulling). Had a strange light headedness which turned into a disconnectedness after an hour or so of one cup!

Can't recommend it. Didn't know about its possible side effects and bans. The locals drink it regularly but they don't really drink alcohol or smoke and their life expectance is lower than in the west.

Re: VMD statement on Calmex

Robin Grimmer — Wed, 09 Nov 2011 16:52:14 GMT

[quote user="Mark Rowland"]

Years ago I went to Fiji to visit my dad who was working out there.

We went to the wedding do of a friend of his. It was very strange.

The caterers were constantly waving flies off the food. the women were sitting separately and the men were all sitting around a bowl of brown liquid and cheering every time they were handed a bowl of the stuff. My father and I took our places and participated in this ritual which was the drinking of Kava root made into tea. My dad (a human surgeon) commented on the likelihood of all the hepatic abscesses he saw originating from the river water used to make this stuff. I had no idea what it was and had my share. it really gives a weird lightheaded feeling. Imagine my surprise when I saw that this was the ingredient in Calmex. Based on what it did to me I don't think it's something I would prescribe.

[/quote]

I visited Fiji in '98 and I also tried some Kava (also known as Yaquna sp?). It was a brown liquid and tasted foul, just like soil!

It wasn't very pleasant but can't recall any ill effects!

Re: VMD statement on Calmex

Martin Atkinson — Wed, 09 Nov 2011 16:31:32 GMT

[quote user="JonB"]

It's not freely available in the UK.

It has been prohibited for use in medicinal products for humans in the UK since 2002:

Original Print PDF

The order only applies to human products, not to animals.

[/quote]

A very quick Google search and I was onto a UK based website and could have filled my basket with Kava.

Re: VMD statement on Calmex

Mark Rowland — Wed, 09 Nov 2011 15:39:39 GMT

Years ago I went to Fiji to visit my dad who was working out there.

We went to the wedding do of a friend of his. It was very strange.