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  1. #1
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    Default Enalapril (ACE inhibitor) for small dogs with cardiac issues?

    Anyone have experience/advice using enalapril for an older, small dog with asymptomatic mitral valve issues?

    Backstory: my 14.5 year-old Papillon-Chihuahua mix (6.5 lbs) has had a heart murmur forever that has now progressed to Stage III/IV. He had an ultrasound today which showed -- no surprise -- some pretty fugly heart valves (mitral and, to a lesser extent, the tricuspid).

    The specialist vet and the regular vet are recommending a daily dose of enalapril. The dog is asymptomatic and leading a normal old-dog life.

    The regular vet suggested I look online for more info on enalapril as she was not well-informed. And so I did. The literature seems to concede, at most, a 'mild' (not 'moderate') benefit to treating asymptomatic mitral valve regurgitation with enalapril. Some studies don't find any benefit.

    Then I see that one of the side effects of enalapril is a lower blood supply to the kidneys that can lead to kidney failure.

    My dog's kidneys are also in the early stages of kidney disease. He did have a recent urinalysis that showed his urine was still concentrating well. The vet was surprised given the dog's blood values.

    The vet and I seem to differ on a few things. She thinks it would be a 'terrible shock' if my dog died in his sleep. I hope my dog dies in his sleep. I hope all my animals die in their sleep when they're old. I can't think of a better way to go. Today, she said he could go running across the backyard and suddenly, it's over. Again, I think that's a happy ending.

    My goal is for my dog to be comfortable. I don't want to give him something that leads/contributes to renal failure. I don't want to give him something that may prolong his life by a few months but leaves him feeling weak or lethargic (which appears to be the most common side effect). While I'll miss him terribly, I don't have any issues with the fact that he's old and not going to be around much longer. But OTOH, I don't mind at all giving him medication that may help and doesn't negatively impact his quality of life.

    So -- does anyone have experience with enalapril and small breed dogs?
    Last edited by JER; Jun. 23, 2009 at 10:46 PM.



  2. #2
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    Nearly 10 years ago we started our 11 year old Black Lab on Anypril for the beginnings of canine dementia. It did help some for him but the cost was HUGE, even though I worked for the vet and received a substantial discount. In the end we all agreed that it was easier and gentler to my old fart to lovingly direct him out of corners when he got stuck and clean up the occasional "Accident" when he forgot to go out.

    I recently lost a very old senior dog to heart failure. And no, we did not put him on medication and yes, he did die here at home on his bed after resting very peacefully for a day. I had my arms around him when he passed. And just a year ago I lost another to a stroke, he was gone in less than a minute and totally unexpected. Like with Mr. Moo, Ralphy died in my arms.

    We adopt Senior dogs, most have serious health issues and we have lived through just about everything. I will only say that you alone need to weigh the pros and cons and decide what is best for your dogs quality of life. No one knows your dog better than you do
    I Loff My Quarter Horse & I love Fenway Bartholomule cliques

    Just somebody with a positive outlook on life...go ahead...hate me for that.



  3. #3
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    Hope this helps--direct quote from VIN (vet information network) from the cardiac FAQ

    ACE-I = enalapril

    "Over the last few years, recommendations have been made to clinicians to institute ACE-I therapy when a murmur is detected. This strategy was recognized to be flawed, because (A) the murmur may not be associated with structural heart disease and (B) the murmur may be associated with mild heart disease that will never progress to a clinical stage. Indeed, one unpublished study suggested that as many as 60-70% of small breed dogs with mitral valve disease may never develop clinical signs. Another study (VETPROOF) showed that over a 5 year period, only half of the animals enrolled in the trial reached the primary endpoint of congestive heart failure.

    These recommendations were then changed to "begin ACE-I therapy when there is LA enlargement". Several placebo controlled studies in dogs with mitral valve disease (SVEP, VETPROOF) examined the potential of ACE-I to delay or prevent the onset of CHF in dogs with mitral valve disease. These studies have uniformly demonstrated that initiating ACE-I therapy prior to the onset of congestive heart failure (pulmonary edema or ascites) does not delay the onset of clinical signs, and does not prolong survival. One placebo-controlled study in cats with HCM failed to show a reduction in cardiac mass (ie hypertrophy) in those cats treated with an ACE-I. Thus, there is no evidence that early ACE-I therapy alters the course of cardiac disease in dogs or cats.

    Data from dogs with DCM are even more scarce. One unpublished study in Dobermans showed a potential survival benefit of ACE-I therapy in subclinical DCM in one subset of patients (neutered males). Why a benefit would be restricted to a single gender state does not make much physiological sense. Thus, these results should be viewed skeptically.

    Thus, ACE-I should be prescribed as part of managing congestive heart failure. Basically, if the patient does not require diuretic therapy, they do not require ACE-I therapy."
    From now on, ponyfixer, i'll include foot note references.



  4. #4
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    We've had our chihuahua on Enalapril for several years now, and she's much happier and livelier on it. She felt like crap before then - lethargic and tired. She has the same thing (grade III/IV heart murmur, slight enlargement). We've just had to add theophylline to the mix as she's getting worse (she's 15, by the way) but she's doing a bit better. She had a bout with pancreatitis (I posted about that a while back) but she seems more comfortable now.



  5. #5
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    Thanks for the replies. This is exactly the kind of stuff I wanted to hear.

    FWIW, my dog has no cardiomyopathy/enlargement issues. It's just the valves. Heart murmur was a II as of Sept 08 so the change to III/IV is the 9 mos or so since then.

    What I'm seeing online is that vets tend to prescribe it in asymptomatic dogs but the studies don't really support it, at least not for mitral valve regurgitation.

    thatmoody, how long has your dog's heart murmur been a III/IV? (I'm encouraged to hear that enalapril has been a good thing for your dog.)



  6. #6
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    I have used it on my Dobes along with Pimobenden (Vetmedin). These dogs all had DCM though and were all over 85lbs. They also took Lasyx which is why kidney values were monitored, I didn't think the Enalapril was a concern in that respect but maybe with little dogs it is different?? Anyways, the cocktail above does increase survival times in Dobes. 2 out of my last 3 to die from CHF had murmers as well. Perhaps none of that is helpful to you.

    I agree with you 100% about sudden death being "ok". It is funny how vets don't seem to see how much better that is....especially for the dog!! One of mine did die this way and it was shocking and hard but much easier than having them pts. With my last one we could not get the cocktail right and he was not happy. He was dying for sure but I actually had him pts because he was feeling so crappy from the side effects of all the drugs and embarrassed about vomiting and having diahrea. Just couldn't treat him like a science experiment until we got it right only for him to live 1 week or even 1 month.

    Anyways, I understand what you are going through and it sucks and I am sorry. Heres hoping you can keep your little guy comfortable for a long time, no matter what you decide.
    "look deep into his pedigree. Look for the name of a one-of-a-kind horse who lends to his kin a fierce tenacity, a will of iron, a look of eagles. Look & know that Slew is still very much with us."



  7. #7
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    Do you have a reference for the increasing renal damage? Ace inhibitors are commonly used in human medicine and also recomended by veterinary nephrologists for slowing the progression of the disease. My husband has a rare kidney disease and takes an ace inhibitor to protect his kidneys.


    I'm guessing your are looking at contraindications for higher doses. Proper doses should be fine, just don't overdo it.
    Turn off the computer and go ride!



  8. #8
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    I'd say about 2 years since we discovered it was that bad. It went from not much of a murmer to IV pretty quickly, but it's stabilized, and even improved a bit, since then (last checkup the vet felt it was around III again - it goes up and down, although her heart is still a bit enlarged - she has no fluid buildup yet, though). She had a horrid cough, but we finally determined that it was from a narrowed trachea, and so have to balance the occasional steroid taper with the fact that prednisone can affect her pancreas. Her heart is really not the worst of her problems, although it's been pretty serious for quite some time. She sleeps a lot more than she used to, but she still has a very good appetite and has the occasional frisky spells, but she IS 15.

    Oh, and she was also on Lasix for quite some time, but they've phased it out now that she's doing so well on the Enalapril.



  9. #9
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    Quote Originally Posted by foggybok View Post
    Do you have a reference for the increasing renal damage? Ace inhibitors are commonly used in human medicine and also recomended by veterinary nephrologists for slowing the progression of the disease. My husband has a rare kidney disease and takes an ace inhibitor to protect his kidneys.


    I'm guessing your are looking at contraindications for higher doses. Proper doses should be fine, just don't overdo it.
    It *is* used in dogs and cats that have protein losing nephropathies and can decrease disease progression. However, in otherwise normal dogs it can raise the BUN/Creat (this is actually expected), which is not the same as kidney failure. Monitoring is necessary to make sure that it does not tilt in that direction over time.

    So the short answer is, it depends!

    I would not personally prescribe it in a pet with a murmur without a diagnosis of heart enlargement or early failure. And then I usually prescribe it with lasix as well.
    From now on, ponyfixer, i'll include foot note references.



  10. #10
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    How ironic that you post this today.

    I was waiting at the vet today to pick up my dog when I overheard a vet discussing with a patient putting her small dog on Enalapril for a heart issue. I don't know what the specific heart condition is.

    The conversation caught my ear though because my dog started Enalapril about 2 months ago after being diagnosed with Protein Losing Nephropathy. (PLN.) He's a Soft Coated Wheaten Terrier. He was at the vet today for followup blood and urine testing and to make med adjustments if necessary. PLN causes the dog to lose protein through its kidneys. Given that Enalapril is used to help stop or slow that loss, I don't think that your concern about the kidney side effect needs to be a major one. (I'm not a vet however, so maybe a heart issue causes Enalapril to interact differently with the kidneys, so certainly question your vet. )

    Also, I've done yearly bloodwork and urine on my dog. When we caught the changes it was in the blood only. Like your dog, he was still concentrating his urine within normal ranges, which was a bit surprising considering where his blood levels were. I suppose I will have more info tomorrow when the blood and urine results are in, (hopefully positive results.)

    What I heard this vet say was that there is another medication out there that is new; (I don't remember the name,)and it is very good. However, they generally start with Enalapril because it usually is effective, and if it's not, you still have something else to try. This woman was from out of state and he recommended to her that she just wait until she got back home and then establish a relationship with her vet to make the decision on the treatment, or with a specialist. Since you wrote you have a specialist, it sounds like you are already well on the way and trying your best to do right by your pup.

    I wish you the best of luck. I know how difficult and confusing it is.

    MM

    Btw, The conversation between vet and client was in the waiting room about 6 feet away from me. I wasn't just listening in at a door.

    "Here, hold my dog would you? I can't hear them?"


    Quote Originally Posted by JER View Post
    Anyone have experience/advice using enalapril for an older, small dog with asymptomatic mitral valve issues?

    Backstory: my 14.5 year-old Papillon-Chihuahua mix (6.5 lbs) has had a heart murmur forever that has now progressed to Stage III/IV. He had an ultrasound today The specialist vet and the regular vet are recommending a daily dose of enalapril. The dog is asymptomatic and leading a normal old-dog life.

    The regular vet suggested I look online for more info on enalapril as she was not well-informed. And so I did. The literature seems to concede, at most, a 'mild' (not 'moderate') benefit to treating asymptomatic mitral valve regurgitation with enalapril. Some studies don't find any benefit.

    Then I see that one of the side effects of enalapril is a lower blood supply to the kidneys that can lead to kidney failure.

    My dog's kidneys are also in the early stages of kidney disease. He did have a recent urinalysis that showed his urine was still concentrating well. The vet was surprised given the dog's blood values.


    So -- does anyone have experience with enalapril and small breed dogs?



  11. #11
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    Quote Originally Posted by foggybok View Post
    Do you have a reference for the increasing renal damage? Ace inhibitors are commonly used in human medicine and also recomended by veterinary nephrologists for slowing the progression of the disease. My husband has a rare kidney disease and takes an ace inhibitor to protect his kidneys.
    I got the info from the package insert. And yes, I know ACE inhibitors can be prescribed in dogs to treat kidney problems.

    My thinking was this: my dog has old-dog kidney issues but his urine is still concentrating very well and he's asymptomatic for kidney disease. As he's compensating now, do I want to take a chance that a new medication might push him into decompensating?

    (I declined to treat kidney issues/Cushings's with the recommended pharmaceuticals in my border collie cross. Instead I focused on a good diet and a Chinese herb (from the vet) and she lived another 5 years, without symptoms, to the age of 16.5.)



  12. #12
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    MiMuneca, I think you're talking about Pimobendan. My vet mentioned it today (and sisu27 mentioned it on this thread) but she said it's not usually prescribed for asymptomatic dogs with valve issues. They do prescribe it, she said, when the dog is symptomatic. She also wasn't sure about using it in a dog of his (lack of) size. I'm not sure how small the dog you saw today was -- my dog is only 6 lbs.

    I hope your dog's tests turn out well. I have my dogs done every six months starting at about age 12 and the resulting patterns are always very interesting. The one dog I had who always had good blood panels (to age 14.5) died very quickly from lymphoma, just days after diagnosis/first presentation of symptoms. With everyone else, there are always a few things to worry about, some more major than others.

    Again, thanks for all these replies.



  13. #13
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    Quote Originally Posted by foggybok View Post
    Do you have a reference for the increasing renal damage? Ace inhibitors are commonly used in human medicine and also recomended by veterinary nephrologists for slowing the progression of the disease. My husband has a rare kidney disease and takes an ace inhibitor to protect his kidneys.


    I'm guessing your are looking at contraindications for higher doses. Proper doses should be fine, just don't overdo it.
    Ok, so it is sort of complicated how ACE-I impair kidneys while protecting them. The functional unit of the kidney is the nephron, the beginning of this is the glomerulus. What the ACE-I do is decrease the pressure within the glomerulus by dilating the vessels feeding into the nephron. So this decreases the kidneys work load because less stuff is getting filtered at all times because there is less pressure pushing it through.

    So you will see an increase in serum creatinine and BUN because those aren't being pushed out quite as much during every pass through the kidney. But the kidney is taking a little break and preventing further damage by pushing more through the nephron than it can handle.

    Does that make sense? You will see kidney-related lab values look worse, but the kidneys aren't actually shutting down more.

    I have a dog with chronic kidney disease and she is on benazepril - it is on the $4 list at Target.
    Laura



  14. #14
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    Hi Jer,

    That's possible that that is the drug. I'm really not sure. It was the mention of Enalapril that caught my attention. This dog was small, I'd say in the 6-12 pound range. In fact, when I first read your post I had to look and see if you were in OH or the other state where this woman said she actually lives! I'm far, far from a vet/Biology type person, but I would dare to say this dog is symptomatic, though of exactly what I don't know. I heard mention of comparisons to people who have had shunts placed, and discussions of quality of life and the such. The dog also had some stitches down its tummy. I didn't spend my whole time eavesdropping though. If I had only known this thread was going to come up I would have taken notes!!

    Thank you for the good wishes for my dog. I've got my fingers crossed. We lost our first Wheaten to this disease years and years ago before they knew much about it. Our 2nd one lived disease free to 16. We donated both of them for research into the disease. I hope they help mine, (and many other Wheatens,) live a long, long life.

    MM

    Quote Originally Posted by JER View Post
    MiMuneca, I think you're talking about Pimobendan. My vet mentioned it today (and sisu27 mentioned it on this thread) but she said it's not usually prescribed for asymptomatic dogs with valve issues. They do prescribe it, she said, when the dog is symptomatic. She also wasn't sure about using it in a dog of his (lack of) size. I'm not sure how small the dog you saw today was -- my dog is only 6 lbs.

    I hope your dog's tests turn out well. I have my dogs done every six months starting at about age 12 and the resulting patterns are always very interesting. The one dog I had who always had good blood panels (to age 14.5) died very quickly from lymphoma, just days after diagnosis/first presentation of symptoms. With everyone else, there are always a few things to worry about, some more major than others.

    Again, thanks for all these replies.



  15. #15
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    Quote Originally Posted by ponygrl View Post
    Ok, so it is sort of complicated how ACE-I impair kidneys while protecting them. The functional unit of the kidney is the nephron, the beginning of this is the glomerulus. What the ACE-I do is decrease the pressure within the glomerulus by dilating the vessels feeding into the nephron. So this decreases the kidneys work load because less stuff is getting filtered at all times because there is less pressure pushing it through.

    So you will see an increase in serum creatinine and BUN because those aren't being pushed out quite as much during every pass through the kidney. But the kidney is taking a little break and preventing further damage by pushing more through the nephron than it can handle.

    Does that make sense? You will see kidney-related lab values look worse, but the kidneys aren't actually shutting down more.

    I have a dog with chronic kidney disease and she is on benazepril - it is on the $4 list at Target.
    Thanks, I'm actually well versed on kidney physiology, it's part of what I do for a living. The reason I asked her source was to see if she was reading something off the label and interpreting it to mean ACEi is bad for the kidney. It is exactly what happened, but I wanted to point out that in fact ACEi is generally good for kidneys and used in the treatment of kidney disease (and prevention of progession, even prior to macroalbuminuria) so properly used it isn't likely to send the dog into renal failure.
    Yes, you can send some patients into acute renal failure, but proper monitoring and dosing should avoid any issues.

    I'm not saying the dog needs ACEi, but wanted to get that out there. Sounds like the OP has a good head on her shoulders.


    And for the OP, I just was talking to three of the top veterinary nephrologists about the treatment for Chronic Kidney disease in dogs. They all agreed diet was on the top of the list, but they did not agree on the need for ACEi. Once said absolutely yes and another said not needed..... So there you have it
    Last edited by foggybok; Jun. 24, 2009 at 11:02 AM.
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  16. #16
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    Quote Originally Posted by JER View Post
    I got the info from the package insert. And yes, I know ACE inhibitors can be prescribed in dogs to treat kidney problems.
    JER - my old Basset was on this drug and the poor little guy had multiple issues.

    Along with Lasix it gave him a few more months. In the end - his heart gave out before his other organs did.

    But those last few months were good ones.

    Hope that helps - and I'm sorry for your troubles.



  17. #17
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    My old JRT dog, Darby, who I lost a few months ago was on Enalapril for over a year. It helped him have a better quality of life. He had congestive heart failure.
    Last edited by Daydream Believer; Jun. 24, 2009 at 09:59 AM.



  18. #18
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    I can only give you my human insights.

    ACE inhibitors are absolutely, positively, one of the 2 cornerstones of treating heart failure. The other drug is beta blockers--not sure the veterinary community has gotten on board with those yet, though. These drugs have taken a general disease state (which has 100 different variations) and turned it from a horrible prognosis to a manageable thing, for the most part.

    HOWEVER, (again, this is based on human medicine knowledge!) the benefit in a heart that has NORMAL PUMPING FUNCTION and leaking valves is less clear. That distinction is probably worth making before deciding to treat--is the heart pumping with normal strength (normal ejection fraction) and the valves are just really leaky? Or is the pump weak (decreased ejection fraction) AND the valves are leaky? In the former case, there is much less evidence that ACE inhibitors are beneficial. In the latter, they would be considered MANDATORY, along with a beta blocker. BOTH are important, in humans. I'd actually say VITAL, or something much stronger than "important".

    Kidney function can be a problem with ACE inhibitors (not so much beta-blockers) and it needs to be watched along with potassium levels, which can go up. BUT sometimes these drugs can actually IMPROVE kidney function by increasing cardiac output. You sort of don't know until you try, but generally we avoid them if the kidneys are pretty far gone. There are substitutes, though--a combination of nitroglycerin and hydralazine is nearly as effective as an ACE inhibitor in heart failure, without the risk of worsening kidney function.

    I disagree with the implication that "kidney function can look worse but the kidneys are actually OK" with ACE inhibitors. If the blood tests look worse, then the kidneys ARE probably getting worse. There are a few drugs that "fool" us with making the bloodwork look worse but the organs are fine. ACE inhibitors are not one of them. Sharp worsening of kidney function when on an ACE inhibitor is a big red flag to stop them. A little elevation in creatinine might be tolerable, though. What I mean is, a slight elevation in creatinine on ACE inhibitor therapy may not be a problem--there ARE benefits of using these drugs in many cases even if the creatinine worsens a little--but it should never be ignored or considered totally benign. If creatinine goes up significantly in my CHF patients on ACE inhibitors I switch over to Nitro/Hydralazine. Almost as effective, safer, and also cheap.

    If I had a dog with heart failure, personally I'd start with a beta blocker (carvedilol) and an ACE inhibitor first, add diuretics as needed, and then maybe digoxin if that wasn't helping. This assumes a dog with a bad ventricle. For "just" leaking valves I'd go with a beta blocker first, adding on the rest only as needed. Just my human-centric opinion.
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  19. #19
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    Quote Originally Posted by deltawave View Post
    I can only give you my human insights.



    I disagree with the implication that "kidney function can look worse but the kidneys are actually OK" with ACE inhibitors. If the blood tests look worse, then the kidneys ARE probably getting worse. There are a few drugs that "fool" us with making the bloodwork look worse but the organs are fine. ACE inhibitors are not one of them. Sharp worsening of kidney function when on an ACE inhibitor is a big red flag to stop them. A little elevation in creatinine might be tolerable, though. What I mean is, a slight elevation in creatinine on ACE inhibitor therapy may not be a problem--there ARE benefits of using these drugs in many cases even if the creatinine worsens a little--but it should never be ignored or considered totally benign. If creatinine goes up significantly in my CHF patients on ACE inhibitors I switch over to Nitro/Hydralazine. Almost as effective, safer, and also cheap.

    I agree with you, fortunately the damage is generally reversible if treatment is stopped right away. You just need to monitor...

    I don't consider any drug totally benign......
    Turn off the computer and go ride!



  20. #20
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    I think we're pretty much on the same page there, foggy. As usual.

    I'm so excited to find a topic I can actually talk about with confidence!
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