Day by Day

Back in January, my Obi was diagnosed with Congestive Heart Failure and Dilated Cardiomyopathy.  (See Anticipating the End.)  Since then, it has been a struggle to keep up with the cost of heart medicines for my adorable baby. (See Pet Insurance…)  But how can you put a price on keeping a loved one in your life – even if it is a furry loved one??  All costs aside, my baby seemed to be doing very well, and no one would ever suspect he was sick.  So as any logical person struggling with the excessive cost would, I began to question the need for the medicines he was on.  First I researched three of the four.  This is what I found through my internet searches (and you may want to skip over this part if you aren’t researching for your own dog’s health):

Benazepril is used to treat high blood pressure (hypertension). Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. Benazepril is an ACE inhibitor and works by relaxing blood vessels so that blood can flow more easily.  This medication may also be used to treat heart failure or to help protect the kidneys from harm due to diabetes.

ACE Inhibitors – Indications

Severe heart disease is generally associated with activation of the reninangiotensin–aldosterone system (RAAS), which promotes fluid retention, vasoconstriction, and myocardial and vascular remodeling. Use of ACE inhibitors in dogs with CHF is associated with improved quality of life and survival; however, data in support of this statement are less robust for dogs with DCM than for dogs with DMVD. When diuretics such as furosemide are administered, the reduction of plasma volume further stimulates RAAS activity and coadministration with an ACE inhibitor is generally recommended.

Administration

There are a variety of ACE inhibitors available, including enalapril, benazepril, ramapril, and lisinopril (Table). Differences are relatively minor, mainly involving route of metabolism/excretion and lipophilicity. From a clinical standpoint, many cardiologists consider them to be interchangeable. In the United States, the two most commonly used ACE inhibitors are enalapril and benazepril; both are associated with clinical benefit in dogs with signs of heart failure.

Considerations

In dogs with DMVD, the use of ACE inhibitors in those without clinical signs remains controversial. Two well-designed studies offer slightly different perspectives: One study in Cavalier King Charles spaniels with mild–moderate DMVD clearly indicated that enalapril did not delay onset of CHF. Another study involving dogs of many different breeds and more advanced DMVD also failed to show benefit with respect to the study’s primary endpoint; however, analysis of several secondary endpoints suggested that dogs that received enalapril avoided heart failure longer than dogs that did not.  In my opinion, if ACE inhibitors delay heart failure in dogs with DMVD that show no clinical signs, the effect is inconsistent from individual to individual, relatively small, and unlikely to dramatically change progression of disease. In dogs with severe heart enlargement and at high risk for CHF, I prefer to use an ACE inhibitor in tandem with low-dose diuretic therapy (furosemide, 1 mg/kg Q 24 H), as this more likely reduces plasma volume, intracardiac pressure, and risk of CHF than using an ACE inhibitor alone.

In human patients with asymptomatic DCM, early use of ACE inhibitors is widely recommended. In veterinary medicine, large-scale trials are lacking; however, a small study indicated that ACE inhibitors delayed onset of heart failure in Doberman pinschers with DCM. Thus, in dogs with DCM, I recommend use of ACE inhibitors prior to onset of clinical signs.

Monitoring

Adverse effects of ACE inhibitor treatment are relatively rare, but clinically significant renal dysfunction can occur. Less commonly, systemic hypotension or electrolyte imbalances are encountered. Renal function should be evaluated both before and after initiation of ACE inhibitors and at 3- to 6-month intervals thereafter.

Sotalol is used to treat a serious (possibly life-threatening) type of fast heartbeat called sustained ventricular tachycardia. It is also used to treat certain fast/irregular heartbeats (atrial fibrillation/flutter) in patients with severe symptoms such as weakness and shortness of breath. Sotalol helps to lessen these symptoms. It slows the heart rate and helps the heart to beat more normally and regularly. This medication is both a beta blocker and an anti-arrhythmic.

Beta-Blockers – Indications

Sympathetic tone is chronically elevated in dogs with DMVD and DCM and is thought to contribute to disease progression. In humans, plasma norepinephrine is a powerful predictor of morbidity and mortality. However, routine use of beta-blockers in veterinary medicine is hindered by lack of well-controlled clinical trials and risk for adverse events when initiating therapy, especially in dogs with advanced disease. In humans, beta-blockade is recommended in virtually all instances of reduced contractility, such as occurs in DCM. Thus, administration of beta-blockers is advocated by many cardiologists in dogs with DCM.

Adminstration

Because of the risk for acute slowing of heart rate and decreases in contractility, treatment with beta-blockers must be performed with caution. Typically, the dose is up-titrated over 4 to 6 weeks with close monitoring of heart rate, respiratory effort, and blood pressure. Titration is best tolerated in dogs with relatively early DCM.

Considerations

In dogs with DMVD, the use of beta-blockers is controversial and no consensus recommendations can be made.

Monitoring

Practitioners who use beta-blockers must be prepared to monitor dogs closely and to deal with acute decompensation should it occur. Consultation with a cardiologist is recommended.

Vetmedin (pimobendan) is used in the management of heart failure in dogs, most commonly caused by myxomatous mitral valve disease (also previously known as endocardiosis), or dilated cardiomyopathy. Research has shown that as a monotherapy, pimobendan increases survival time and improves quality of life in canine patients with congestive heart failure secondary to mitral valve disease when compared with benazepril, an angiotensin-converting-enzyme (ACE) inhibitor.[2] However, in clinical practice, it is often used in conjunction with an ACE inhibitor like enalapril or benazepril.

Indications
Both DMVD and DCM are associated with progressive loss of myocardial contractility. Poor contractility is much easier to detect in dogs with DCM as opposed to DMVD, where the presence of a large degree of mitral regurgitation often confounds routine echocardiographic evaluation of contractility.

Pimobendan is a positive inotrope and increases contractility through a mechanism different from that of traditional inotropes such as digoxin—the advantage of which is increased contractility without significant increases in myocardial oxygen demand. Pimobendan also relaxes vascular smooth muscle and elicits modest arterial vasodilation; this dual “inodilating” action is unique. Pimobendan improves survival and quality of life in dogs with DMVD, and very likely does the same in dogs with DCM.

Administration
The recommended dose is 0.5 mg/kg per day, divided into 2 doses that do not necessarily need to be equal.

Considerations
The benefits of pimobendan have been substantiated in dogs showing clinical signs associated with heart disease due to DMVD and DCM; treatment with this agent is recommended only if clinical signs are evident. Thus, in the majority of instances, pimobendan is prescribed only if and when dogs experience congestive heart failure and its attendant clinical manifestations (eg, cough, dyspnea, tachypnea).

Less commonly, dogs with exercise intolerance or syncope are also candidates for treatment. Currently, no evidence exists for the use of pimobendan in dogs with DMVD or DCM prior to the onset of clinical signs.

Monitoring
Pimobendan is generally well tolerated in dogs and no specific monitoring recommendations accompany its use.

The fourth medicine (Salix), I did not bother researching, because I already knew this one was desperately needed to help keep fluid from building up in his lungs.  As you can guess, I was researching the others to see if I could drop any of them from the mix to save some money.  After reading about them, I concluded (and it’s possible I was wrong), that three of the four were taken by humans, but the fourth (Vetmedin aka Pimbendan) was not.  This pill just happened to be the most expensive at $110 for a 25 day supply from my vet.  I thought I would try to go without and see how he reacted.


At first, Obi seemed fine without the Vetmedin, but within a day or two I started to get paranoid about going without.  Therefore, I went online and found it cheaper ($88 a month).  I submitted an online order.  Since this is a prescription medicine, the company indicated they would require a prescription from the vet and would attempt to get it.  I waited.  Two days later (on a Saturday) I started to get worried, so when Obi ran out of his salix and I had to call the vet for a refill, I asked about the prescription. The company had not sent the vet a request.  I figured I would give them until Monday.

Sunday morning, during our normal routine, I was up bright and early (6:30 am – way too early for a weekend if you ask me) and gave Obi his medicine.  Since I was awake, I started to make my coffee.  Behind me I heard a thud.  I turned around and my precious baby was lying flat on his side staring wide-eyed at me. I ran over to him and tried to help him up.  He couldn’t move.  I watched for signs of a seizure.  He did not shake at all, just laid there as if he were paralyzed.  I started to panic.  I thought this was it.  I woke the kids up, because I was afraid this would be their last chance to say goodbye.  We spent the next hour laying on the floor with him.  All we could do was give him love.  Then he slowly started to get up and I asked him if he needed to go out.  He did.  He moved slowly, but as the day progressed, he worked his way back to being somewhat “normal”.  He was slower than his normal spunky self, and I could hear the fluid in his lungs, but he seemed to be OK.  A trip to the vet in the morning would be priority.


On Monday, he went to the vet and got an injection to drain the fluid from his lungs.  We also got a new supply of his vetmedin since the online company never followed-through to obtain a prescription from the vet.  That evening he was back to his spunky self.  It was settled, he would stay on all four medicines for the remainder of his life.  Happy as I was that he was doing better, I faced a new dilemma.  I have a vacation coming in a week.  A “kid vacation” if you will…the last one we will have before Virginia graduates high school and goes off to college.  I originally thought to board the dog with the vet so that I knew he would receive good care; but now I didn’t want to leave him.  Even though the staff at the vet’s office loves Obi, and even with the amount of attention they would give him, I knew there would be periods of time that he would spend in a kennel, alone.  I don’t want him to feel abandoned.  And if this happens to be his time, I don’t want to chance him dying “alone”.  I didn’t want to cancel this trip either.

I spoke with my mom (who lives a few states away), and she agreed to take him.  As fabulous as this is, and yes it is an awesome deal for both Obi and myself, it still worries me.  At the vet, he would have been dropped off the day we left, and picked up the day we returned.  Since my mom lives a few states away, I am now taking him to be with her a week prior to our trip.  That’s a week I won’t have with my baby.  I know, silly right?  But unless you have a fur baby that you deeply love, you cannot imagine how hard it is to leave your baby, especially when they are deathly ill.  Still, I have no other choice, and this is the best one.

So, we are now taking it day by day.  I listen each night as his breathing grows more “liquid” and labored.  I listen to him cough to try to eliminate it from his lungs.  My baby is slowly drowning and I feel helpless that there is nothing that can be done to reverse it all.  When I leave for work each day, I kiss him goodbye and hope when I return at the end of the day he will still be at the door to greet me when I get home.  Day by day.  That is all I can do.  That and love him with everything I have.

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2 comments on “Day by Day

  1. Pingback: Facing the Inevitable | My Inspirations

  2. Pingback: The Hardest Day of My Life | My Inspirations

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