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Brian M
16th September 2011, 11:56 AM
Hi

I am not happy about Daisy still taking Frusemide and would much prefer her to be on Zitac ,but
who would I approach to get it changed would I need to go back to Geoff Skerritt or should I
just go to my own Vets .If I can get it changed what dose would you think would be suitable as she
is on only 10 mg of Frusemide daily .

Kate H
16th September 2011, 01:31 PM
If you're going to continue to use Geoff Skerritt as your neurologist I should have a word with him - your vet will probably consult him anyway. Also note that Clare Rusbridge has removed frusemide from the latest edition of her treatment algorithm.

Kate, Aled and Oliver (in haste, at it's my turn to go to the vet's - ie a hospital appointment!)

Pat
16th September 2011, 04:46 PM
Brian - go back and tell Mr. Skerritt your concerns and the comments from Simon Swift and tell him you want to change. There should be no reason that he should not agree to that. I wouldn't wait to hear back from Simon; there is enough reason for concern already. The neurologist should always be in charge of what drugs your dog should take for SM.

Kate - I'm so pleased to read your news. As some of you know, I've been concerned about the use of furosemide (US spelling) for SM ever since the drug first became part of the treatment protocol.

Does anyone plan to circulate this updated protocol through the various SM lists? If not, I'll post this weekend to the groups to which I belong.

Pat

Pat
16th September 2011, 05:36 PM
Also note that Clare Rusbridge has removed frusemide from the latest edition of her treatment algorithm.

Kate, Aled and Oliver

I just looked at Clare's website and I see that the treatment algorithm has been changed and furosemide was removed. The typeface is slightly different so it's obvious that there was a deliberate change to the algorithm. However, the body of her SM tutorial remains the same where there is discussion of what drugs are used to treat SM -

http://www.veterinary-neurologist.co.uk/part4.htm#35

I can't determine if this is an oversight, and I don't want to assume that she no longer recommends using furosemide without knowing for certain so I won't post anywhere else. Anyone know?

I also found this interesting bit of trivia that I copied and pasted - Furosemide (INN) or frusemide (former BAN) - INN is international nonproprietary name or official generic name given to a pharmaceutical substance determined by the World Health Organization. A British Approved Name (BAN) is the official non-proprietary or generic name given to a pharmaceutical substance, as defined in the British Pharmacopoeia (BP).

Pat

Brian M
16th September 2011, 08:51 PM
Hello Ladies

Thanks for the push.I phoned Chestergates at 4.00 pm Geoff was there but I only spoke through his assistant who after I explained Simon's and my concern about Daisy being on frusemide the comment came back for me to speak to Simon as they had been in contact with each other about Daisy .Phoned North West Surgeons and Simon is off this week but back Monday so had a quick word with another Cardio who advised me to speak to Simon on Monday .Not too happy about this as I feel poor Daisy is in the middle and as GS prescribed the Frusemide I feel the change of medication would be more his decision ,but I intend to fully resolve this on Monday for certain.
Pat just send a pm .

Kate H
17th September 2011, 12:15 PM
Pat wrote: the body of her SM tutorial remains the same

Hi Pat, have you looked at the latest version? I downloaded it on Tuesday and there is no mention of frusemide anywhere, only cimetidine (Zitac) and omeprazole.

I think if Oliver was prescribed Zitac I would go bonkers - the recommended dose is 3 times a day, 2 hours after giving other drugs (in Oliver's case, gabapentin every 8 hours), so I'd be giving alternating gabapentin and Zitac 6 times a day - presumably starting with gabapentin at 6am and finishing with Zitac at midnight! :sl*p:

Kate, Oliver and Aled

Pat
17th September 2011, 04:32 PM
Kate - As you say, furosemide is not mentioned on the chart but furosemide is still mentioned in the part of the website (I gave the link) that describes SM treatment and lists the potential drugs that are used. I don't know if that is an oversight (removed it on the chart but not from elsewhere in the SM discussion on the site) or not.

I agree that medication schedule would be difficult - esp for a working person. Guess I'd have to use omeprazole if I were treating an SM dog.

Pat

Kate H
17th September 2011, 04:54 PM
Sorry Pat, thought you were just talking about the treatment algorithm - I hadn't looked at the rest of the website. Perhaps she left it in elsewhere because she is realistic enough to know many vets will go on prescribing frusemide so need to know the drawbacks. I'm having a bit of a fight with one of the younger vets in my local practice, who in spite of training in London seems never to have heard of Clare, and has no idea why 'that woman' (as she calls her!) is suggesting not using it - seems to think she's just another neurologist with a bee in her bonnet!. I discussed with her moving Oliver off frusemide simply because his photo phobia (caused, according to an ophthalmologist, by his dilated ventricles) is getting worse, so his present dose of frusemide obviously isn't doing its job of reducing pressure.

The problem is, of course, that no vet can be expert in every canine disease and I think I'm the only one in this practice with a dog with confirmed SM (which doesn't mean of course that there aren't others with undiagnosed SM). I really miss the vet who left a few months ago to go home to Ireland (lucky Ireland!), who did her internship at Stone Lion and was very clued up about SM.

Kate, Oliver and Aled

Sabby
17th September 2011, 08:09 PM
Pat wrote: the body of her SM tutorial remains the same

Hi Pat, have you looked at the latest version? I downloaded it on Tuesday and there is no mention of frusemide anywhere, only cimetidine (Zitac) and omeprazole.

I think if Oliver was prescribed Zitac I would go bonkers - the recommended dose is 3 times a day, 2 hours after giving other drugs (in Oliver's case, gabapentin every 8 hours), so I'd be giving alternating gabapentin and Zitac 6 times a day - presumably starting with gabapentin at 6am and finishing with Zitac at midnight! :sl*p:

Kate, Oliver and Aled


I am a bit confused you say the recommended dose for Zitac is three times a day. Harley & Ebony are on 100mg only 2x a day. And I never knew that you have to give it two hours after giving other drugs. I read the instruction leaflet and it doesn’t tell you anything about when and how to give it. I just give mine after food.

Nicki
17th September 2011, 08:26 PM
It's so confusing isn't it? Kayleigh is on 50mg three times daily, she's only 7.3kg though.

I know Clare Rusbridge says 30 to 60 minutes away from Gabapentin [and presumably other meds] as it can affect their absorption.

NOAH compendium of Data Sheets for Animal Medicines says 5 mg of cimetidine per kg of bodyweight administered three times daily by the oral route

http://www.noahcompendium.co.uk/MSD_Animal_Health/Zitac_Vet_100_mg_Tablets_for_Dogs_and__Zitac_Vet_2 00_mg_Tablets_for_Dogs/-56439.html


Due to inhibition of cytochrome P-450 activity by cimetidine, the metabolism and elimination of some drugs can be reduced.

The increased gastric pH resulting from cimetidine administration may lead to reduced absorption of drugs requiring an acid medium for absorption.


Clare's website says that Cimetidine may increase the kidney clearance of Gabapentin.
This is the link to the treatment algorithmhttp://www.veterinary-neurologist.co.uk/syringomyelia/docs/treatalgo.pdf

Kate H
17th September 2011, 08:44 PM
I was just going on Clare's latest version of her treatment algorithm (recommendations for vets), which omits mention of frusemide and recommends two other CSF reducing drugs. At the top she says 'Start CSF pressure reducing drugs e.g. cimetidine (Zitac) ... orally 3 times daily' and at the bottom she has a note: 'Because cimetidine reduces stomach acid it may reduce the absorption of other drugs. It is recommended that other drugs are administered at least 2 hours before the administration of cimetidine.'

I would guess that Harley is only on twice a day because he so far only has a pre-syrinx, and Clare always seems to recommend starting drugs low, and the time gap doesn't apply because he's not on other drugs (such as gabapentin).

Kate, Oliver and Aled

Brian M
17th September 2011, 09:17 PM
Hello Kate

You know Chestergates ,I wonder what made G.S. prescribe frusemide and not either of the other two which seem a much safer
option to start Daisy with .

Nicki
17th September 2011, 09:36 PM
'Because cimetidine reduces stomach acid it may reduce the absorption of other drugs. It is recommended that other drugs are administered at least 2 hours before the administration of cimetidine.'




Thanks Kate - that is a huge problem though, Kayleigh is on Gabapentin three times daily, 7am, 3pm and 11pm. If I have to give that 2 hours before the Cimetidine, it means I have to give her the Cimetidine at 1 am :( I already take my meds at 11pm and 3am, not sure I can cope with setting the alarm for 1am too! I can only think to give it to her at 3am.

I think perhaps this needs to be checked with Clare? Maybe we can reduce it to twice daily that might be more practical, if the drug will still work like that.


Omeprazole is a concern, in humans there is a risk of bowel cancer with long term usage :( Pulse therapy is recommended, where you have 4-6 weeks on, 1-2 weeks off. It's not known about long term risk in dogs.
I also found that high doses and long-term use (1 year or longer) may increase the risk of osteoporosis-related fractures of the hip, wrist, or spine.


For Pat and anyone else interested:

My vet contacted Gregg Kortz DVM Diplomate ACVIM - Neurology back in 2007 about the long term use of Omeprazole - at that time he had only be using it for about a year, but had not seen any problems in that time. He kindly sent some a few of the articles on Omeprazole toxicity.


Neuroendocrine cell hyperplasia and neuroendocrine carcinoma of the rodent fundic stomach.
Poynter D, Selway SA.
Glaxo Group Research Ltd., Ware, Herts, U.K.

Certain substances when given orally to rats have effects on the neuroendocrine cells of the fundic stomach. Such compounds also have effects on acid or its secretion, which is to a greater or lesser extent suppressed, with a consequent rise in serum gastrin, followed by an increase in the number of histamine-secreting ECL cells. These changes are seen with the histamine H2 receptor antagonists loxtidine, SKF 93479, ICI 162,846 and ranitidine; with the hypolipidaemic agents clofibrate, ciprofibrate and benzofibrate; with sodium bicarbonate and pentagastrin; and with omeprazole, a potent inhibitor of the parietal cell proton pump mechanism. Changes in the pH of the rat stomach stimulate the neuroendocrine G cells of the pylorus to secrete gastrin, which acts on the ECL cells of the fundus causing the production of histamine, which in turn stimulates the parietal cell. This sequence leads to an excess of circulating gastrin, which is detectable within 5 days. Subsequently increases in the number of ECL cells occur, the hyperplasia being related to hypergastrinaemia and the degree of acid suppression. The hyperplastic response is rapid, being so obvious with loxtidine at 39 days that there is good reason to suppose it could well be detected earlier. Using omeprazole, hyperplasia was found at 28 days after oral doses of 140 mg/kg/day. In order to get an equivalent degree of acid suppression with ranitidine it was necessary to deliver 420 mg/kg/day by subcutaneous infusion using an osmotic minipump, when hyperplasia occurred. Interestingly, only omeprazole produced a hyperplastic response of G cells. Such results reflect the covalent binding of omeprazole to the proton pump as opposed to the competitive binding of ranitidine to the histamine H2 receptor site. In addition to ECL cell hyperplasia there is ample evidence from lifetime studies in rats and mice that neoplasia may result. Neuroendocrine carcinomas (carcinoids) of the rat fundic stomach have been observed with loxtidine, omeprazole, SKF 93479 and ICI 162,846. They are seen late in the 2-year rat studies and are most unlikely to have arisen purely as an extension of the hyperplastic response. It is possible that the prolonged disturbance of gastric homoestasis resulting from achlorhydria result in the production of a carcinogen or carcinogens, in which event it is not too surprising, in view of the neuroendocrine hyperplasia, that the tumours seen are neuroendocrine carcinomas.(ABSTRACT TRUNCATED AT 400 WORDS)




Pharmacology and toxicology of omeprazole--with special reference to the effects on the gastric mucosa.
Carlsson E, Larsson H, Mattsson H, Ryberg B, Sundell G.
Omeprazole is a long acting inhibitor of gastric acid secretion in different species including rat and dog. Due to the long duration of action, steady state inhibition at repeated once daily administration is reaches within 4-5 days in dogs and in about 3 days in rats. Daily dosing at high dose levels results in virtually complete 24-hour inhibition of acid secretion in experimental animals. The elimination of the inhibitory feedback effect of acid on gastrin secretion leads to hypergastrinaemia. Because gastrin has a trophic effect on the oxyntic mucosa, the hypergastrinaemia results in a reversible hypertrophy of the oxyntic mucosa and an increased capacity to produce acid following maximal stimulation with exogenous secretagogues after discontinuing treatment. Despite the increased capacity to produce acid, basal acid secretion seems to be unchanged. The pronounced hypergastrinaemia which occurs during long-term treatment with high doses rapidly normalizes after discontinuing treatment. The hyperplasia of the oxyntic endocrine ECL cells, and the eventual development of gastric ECL cell carcinoids after lifelong treatment of rats with high doses, can also be attributed to the hypergastrinaemia developing after almost complete elimination of gastric acid secretion in these animals.




Toxicological studies on omeprazole.
Ekman L, Hansson E, Havu N, Carlsson E, Lundberg C.
As part of the safety evaluation of the gastric antisecretory drug, omeprazole, toxicological studies have been performed in several species of animals. The acute toxicity after oral administration to rodents was low. The oral LD50 value was above 4 g/kg. The general toxicity after repeated administration has been studied in rats and dogs. No clinical signs of adverse reactions were seen. Some minor changes in hematology parameters were observed. In rats and mice decreases in the erythrocyte count, hematocrit and hemoglobin have occasionally been found at doses of 125 mumol/kg/day and more. Hyperplasia of oxyntic mucosal cells, concomitant with increases in stomach weight, oxyntic mucosal thickness and folding, has been observed in the species investigated, the dog, rat and mouse. In addition, slight chief cell atrophy and eosinophilia of the chief cell granules were observed in rats. The oxyntic mucosal effects were reversible upon treatment being discontinued. In the oncogenicity studies, gastric carcinoids occurred in the rat but not in the mouse. Investigations of the carcinoids showed that the vast majority of the endocrine cells could be characterised as ECL-cells. The hyperplasia of oxyntic mucosal cells, including hyperplasia of endocrine ECL-cells and development of gastric carcinoids in rats, is attributable to the pronounced hypergastrinemia produced as a secondary effect of almost complete inhibition of acid secretion by the large doses of omeprazole used in the toxicity studies. In agreement with this hypothesis, the hyperplasia of the oxyntic cells was prevented by antrectomy. The reproduction studies performed in rats and rabbits showed no sign of fetal toxicity or teratogenic effect. The results of the short-term mutagenicity tests, Ames test, the micronucleus test in mice and the mouse lymphoma test were all negative.




A review of the effects of long-term acid inhibition in animals.
Carlsson E.
Gastrointestinal Research, AB Hässle, Mölndal, Sweden.

Studies with H2-receptor antagonists have revealed a trophic effect on the gastric mucosa - an effect which has been ascribed to hypergastrinaemia secondary to acid inhibition. Such hyperplasia of oxyntic mucosal cells has also been demonstrated in chronic toxicity studies following profound, long-standing inhibition of gastric acid secretion with omeprazole. The central role of gastrin in this effect was clearly demonstrated in the omeprazole studies, as antrectomy prevented this effect in both rats and dogs. The hyperplasia was fully reversible in both species. The close correlation between serum gastrin and hyperplasia of enterochromaffin-like (ECL) cells in the rat oxyntic mucosa has been demonstrated in a large number of experiments using different means to induce hypergastrinaemia, including administration of exogenous gastrin, treatment with antisecretory drugs and partial fundectomy. The hyperplasia of ECL cells was fully reversible even after 1 year of sustained gastric acid inhibition following treatment with a high dose of omeprazole. Marked long-standing hypergastrinaemia explains the findings of gastric ECL cell carcinoids in the life-long rat toxicity studies with both omeprazole and other inhibitors of gastric acid secretion.



***If anyone is using Omeprazole and wants to continue with it, I have a supply of capsules here which I am happy to send on! [ideally in exchange for a donation to Rupert's Fund ;) but that's not essential!]***

Kate H
17th September 2011, 09:37 PM
I think the move away from frusemide is a fairly recent thing, and that not all neurologists are yet convinced that the drawbacks with it outweigh its usefulness. All drugs have side effects and each practitioner has to weigh up whether in their experience the good effect of any drug is worth the uncomfortable side effects or risks. And dogs are individuals - what works well with one doesn't necessarily work as well with another. I know Ulrika Michal at Chestergates has tried one of the other CFS reducers that Clare recommends (can't remember which one it was) and didn't find it particularly useful, so they may be waiting to see what results Clare gets before committing themselves to the change (I expect she'll write a paper about it!).

Kate, Oliver and Aled

PS Nicki, you echoed my thoughts in an earlier post about the nightmare of trying to fit in both gabapentin and Zitac three times a day!!

Karen and Ruby
17th September 2011, 09:42 PM
This has all confused me a little bit- I have always given the Zitac alongside Rubys dose of pregabalin although she gets her 2nd dose half way through the day on its own- I'd never heard of not giving it alongside each other.

Charlie also has Zitac but he isn't on anything else so it doesn't matter so much.

I'll have to ask her when Charlie goes back in a few weeks.

I must say it would be a whole lot easier to only give 100mg twice a day as I work full time!!

Brian M
17th September 2011, 09:49 PM
Hi Kate

I have fortunatley always been in good health and never missed a days work since a car crash nearly
killed me ,collar bone all my ribs on right ,right leg and right arm in three places ,and have always
had an outlook on life to face problems as and if they arrive, so with my Daisy I am on a very steep
learning curve so any advice and guidance from you ,Nicki ,Pat and many others is more than welcome.

Thank You Ladies .

Ps Never even seen PDE and dont intend to ,that would get me worried and am too much
of a coward .

Nicki
17th September 2011, 09:49 PM
Brian, Frusemide was originally the standard treatment for Syringomyelia. It is only recently that I have heard about Simon Swift's concerns [shown on this thread http://www.cavaliertalk.com/forums/showthread.php?39358-Daisy-More-Bads-News-From-Chestergates-Last-Night&highlight=simon+swift]

I found some info about the RAAS if anyone wants to read up

http://en.wikipedia.org/wiki/Renin-angiotensin_system

In brief it increases the volume of fluid in the body, which also increases blood pressure.


Teddy was on Frusemide for quite a few years, he ended up with a grade 5 to 6 heart murmur aged only 6 :( He was also having liver issues - we suspected due to all the medication. His breeders' lines were normally pretty good for hearts - but I'm now wondering if this was connected to the Frusemide? Need to have a look into this when I'm feeling a bit more awake :(

Nicki
17th September 2011, 09:52 PM
PS Nicki, you echoed my thoughts in an earlier post about the nightmare of trying to fit in both gabapentin and Zitac three times a day!!

Sorry Kate, yes meant to comment on that! Half asleep tonight so it's hard to take all this in :mad:

Think I was composing my last post when you posted so have duplicated you a bit :(

Brian M
17th September 2011, 10:15 PM
Nicki

As I posted previously Simon is going to ring me on Monday to sort this out I think he
may have been away to a cardio conference either last week or the week before, and
he said to me he was going to seek majority advice from his colleagues about this point and then
advise me on whether Daisy should take fortekor to counter the RAAS effects that taking frusemide
seems to stimulate or we go back to GS for a change of diuretic. At Daisy's appoitment he made
comments that the frusemide and RAAS problem had not been addressed before so this seems to
be a new line of thought but then we have Pat's learned advice that she was previously aware that frusemide for a
dog with a murmur doesnt seem to be a good idea .
Hopefully I will get an answer on Monday as with anything to do with the girls I am
pretty tenacious and will not rest until we have a definate opinion ,and will post as
soon as I hear .
Rest easy Nicki pls dont get stressed like I did with Australia loosing today all I was
thinking about was the extra cash for the fund if they win but all is not lost yet .

Brian M
19th September 2011, 11:57 AM
Hi

Just phoned Simon but he is in consultation ,but we will speak as the day goes on .I have printed off
C. .R guidelines together with the NOAH Zitac information .

Brian M
20th September 2011, 11:19 AM
Hi

Just had a phone call from Simon who explained that the question of "whether a dog who has SM and is prescribed frusemide and the dog then develops a heart murmur should continue taking this drug " raised many thoughts and comments amongst the cardiologist community .The consensus of opinion from our American friends indicated not to take the drug ,but without the help of any clinical trials and weighing all points Mr Swift advised that he will email G.S. and ask him to consider putting Daisy on cimetidine instead of frusemide though he is sure there are many Cavaliers affected by both SM and heart conditions that are still taking frusemide .So we wait for a day then I will ring Chestergates to confirm all and switch as soon as I can .Daisy weighs 8 kg so I presume she will take 3 x 50 mg daily of Zitac daily but I know Tagament is a generic of Cimetidine and that is available over the counter but of course is not on the NOAH website .

Nicki
20th September 2011, 12:09 PM
So pleased you are getting all this sorted out - whilst you are speaking to them, can you ask about dosage schedules as above please?

Brian M
20th September 2011, 12:28 PM
Hi Nicki

What shall I ask him ,what dose per kilo of weight ? Simon is a really nice person to speak .

Nicki
20th September 2011, 05:31 PM
Sorry Brian only just seen this :(

There is a bit of confusion over dosage - Clare gives the dose for Zitac [Cimetidine] as 5-7mg per kg 3 times daily BUT

NOAH compendium states 5 mg of Zitac per kg of bodyweight administered three times daily

http://www.noahcompendium.co.uk/MSD_Animal_Health/Zitac_Vet_100_mg_Tablets_for_Dogs_and__Zitac_Vet_2 00_mg_Tablets_for_Dogs/-56439.html


The issue that is concerning me though is that Clare states that as Cimetidine reduces stomach acid, it may reduce the absorption of other drugs. It is recommended that other drugs are administered at least 2 hours before the administration of Cimetidine.


This is giving problems with scheduling medications

Kayleigh is on Gabapentin three times daily, 7am, 3pm and 11pm. If I have to give that 2 hours before the Cimetidine, it means I have to give her the Cimetidine at 1 am!


SO if you get to speak to anyone, can you see if you can get any clarification please? I'm just in the middle of e-mailing my neurologist and I'm hoping someone is also going to speak to Clare about it.

Brian M
20th September 2011, 05:34 PM
Hi Nicki

Understand ,did read the discussion on this point so if I get him will ask .With that regime
you would be up and down all night .

anniemac
20th September 2011, 07:57 PM
Hi

Just phoned Simon but he is in consultation ,but we will speak as the day goes on .I have printed off
C. .R guidelines together with the NOAH Zitac information .

Brian,

Since dr. Swift is a top cardiologist with cavaliers and mvd, I would be curious to see what he says about treating both mvd and sm.

I'm sure he talks to dr. Rusbridge (maybe not) but it would be helpful (just in my opinion) if they could communicate with others if there is a concern with one particular drug used to treat SM and the heart.



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Brian M
20th September 2011, 08:05 PM
Hello Annie

Where have you been .?Could you ask the good
Dr ,poss SS has already consulted with him.

anniemac
20th September 2011, 09:27 PM
Hello Annie

Where have you been .?Could you ask the good
Dr ,poss SS has already consulted with him.

I am sorry!! I missed that part. I saw prilosec side effects, timing of drugs etc. I'm a dummie

Pat
21st September 2011, 12:12 AM
I wanted to respond to this over the weekend and had some computer problems at home. I do have part of a response saved in a word doc at home, but I'll go ahead and start over again from another computer.

I read the pages in Plumb's Veterinary Drug Handbook on cimetidine, and it's a little more complex than what has been said - which is not to give with any other drugs without a two hour window. Basically - the effect of SOME drugs taken with cimetidine is ENHANCED, and the effect of some OTHER types of drugs taken with cimetidine is DIMINISHED. There is a list of these drugs in Plumb's, and there is more extensive info in Plumb's than in the NOAH compendium, but here is a cut and paste from NOAH:

"Due to inhibition of cytochrome P-450 activity by cimetidine, the metabolism and elimination of some drugs can be reduced. Clinically relevant interactions may occur with compounds having a narrow therapeutic index, e.g. beta-blockers, calcium channel blockers, benzodiazepines, barbiturates, phenytoin, theophylline, aminophylline, warfarin and lidocaine. Doses of such drugs may need to be reduced when administered concomitantly with cimetidine. The increased gastric pH resulting from cimetidine administration may lead to reduced absorption of drugs requiring an acid medium for absorption. It is recommended that at least 2 hours should elapse between administration of cimetidine and aluminium or magnesium hydroxide, metoclopramide, digoxin or ketoconazole when possible."

Note that there is no mention of gabapentin or pregabalin type drugs in the above list. Also note that the more common problem is that drug effect is ENHANCED, not diminished. From what I've read, I don't see a problem giving gabapentin and cimetidine at the same time and it seems to be an over-generalization to say not to give ANY other drug at the same time. If I had an SM dog on these meds, I'd want to specifically read and understand where the problem is in Plumb's or another drug handbook. Also, I would consider the option of using one of the other H2 receptor antagonists such as omeprazole, ranitidine or famotidine.

As far as different specialists communicating with each other, I'm afraid that is unlikely to happen. Specialists tend to stick with their own specialty and are reluctant to tread into each other's territory so I would be very surprised to see one specialist give an opinion about treating a disease of another speciality unless perhaps it was something related such as heart failure and kidney failure or hypertension and kidney failure.


Pat

anniemac
21st September 2011, 01:07 AM
As far as different specialists communicating with each other, I'm afraid that is unlikely to happen. Specialists tend to stick with their own specialty and are reluctant to tread into each other's territory so I would be very surprised to see one specialist give an opinion about treating a disease of another speciality unless perhaps it was something related such as heart failure and kidney failure or hypertension and kidney failure.


Pat

You are very right. I know in human practice doctors and specialists can have certain reputations. My brother fits into the arrogant knows everything category, but my step father is a rare bird which I'm very proud of his humble reputation.

He is a retired radiologist but wouldn't even talk about ellas mri, that for the specialists to recommend what to do (even though he has seen CM/SM and several mri's he wouldn't claim to even try to question anything.

Not surprising because I have a friend whose mom is a tech at another hospital but talked about how they all know dr. Gettys because he treats them with as much respect as a brain surgeon. He often will say, "they know more than I do".

What a man, I love that quality but it is not common.

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Tania
21st September 2011, 11:43 AM
Molly and Dougall are on Gabapentin and cimetidine three times per day. We have alwasy been told to leave a two hour window between the two drugs.
As you can imagine it does make life difficult.

Brian M
21st September 2011, 10:16 PM
Hi

Dont know were to start except to say I am highly disappoitment ,irritated and confused and had better not
spill my inner thoughts and feelings here .
A pxxxxx off brian


I'm sorry Brian I understand you are very upset but do not feel it is appropriate to be posting this on a forum which can be read by anyone. If you wish to send this to friends privately obviously you can do this by PM

Tania
21st September 2011, 11:11 PM
I think you have received excellent advise from Simon Swift and also Pat. I would go back to your
own vet and get the cimetidine. Daisy is your dog and I am sure your vet would understand and prescribe.
I think the sooner she is on the correct medication the better. Then perhaps look for a different neurologist.

Sabby
21st September 2011, 11:29 PM
[removed by admin --
please folks: remember to take personal discussions about identifiable professionals private -- as Nicki reminds earlier, they don't belong on a public board.


Thanks -- Karlin]

Kate H
21st September 2011, 11:31 PM
I've been discussing with my vet using a different CSF inhibitor with Oliver (mainly because I think a different one might be more effective). She rang round Chestergates, the Willows and Clare Rusbridge for advice, and all of them actually said leave him on frusemide until he can be scanned again to see how far his eye problems are caused by his dilated ventricles (which for domestic reasons won't be until the new year at the earliest). So at the moment opinion does seem to be divided (in the UK at least) about the pros and cons of frusemide - from what Simon himself has said, not even all the cardiologists are in agreement.

Kate, Oliver and Aled

Nicki
22nd September 2011, 09:51 PM
I read the pages in Plumb's Veterinary Drug Handbook on cimetidine, and it's a little more complex than what has been said - which is not to give with any other drugs without a two hour window. Basically - the effect of SOME drugs taken with cimetidine is ENHANCED, and the effect of some OTHER types of drugs taken with cimetidine is DIMINISHED. There is a list of these drugs in Plumb's, and there is more extensive info in Plumb's than in the NOAH compendium, but here is a cut and paste from NOAH:

"Due to inhibition of cytochrome P-450 activity by cimetidine, the metabolism and elimination of some drugs can be reduced. Clinically relevant interactions may occur with compounds having a narrow therapeutic index, e.g. beta-blockers, calcium channel blockers, benzodiazepines, barbiturates, phenytoin, theophylline, aminophylline, warfarin and lidocaine. Doses of such drugs may need to be reduced when administered concomitantly with cimetidine. The increased gastric pH resulting from cimetidine administration may lead to reduced absorption of drugs requiring an acid medium for absorption. It is recommended that at least 2 hours should elapse between administration of cimetidine and aluminium or magnesium hydroxide, metoclopramide, digoxin or ketoconazole when possible."

Note that there is no mention of gabapentin or pregabalin type drugs in the above list. Also note that the more common problem is that drug effect is ENHANCED, not diminished. From what I've read, I don't see a problem giving gabapentin and cimetidine at the same time and it seems to be an over-generalization to say not to give ANY other drug at the same time. If I had an SM dog on these meds, I'd want to specifically read and understand where the problem is in Plumb's or another drug handbook. Also, I would consider the option of using one of the other H2 receptor antagonists such as omeprazole, ranitidine or famotidine.


Thank you SO much for posting this Pat, that has put my mind at rest. I'm going to forward this on to my neurologist too.

Just found the appropriate section in the British National Formulary http://bnf.org/bnf/bnf/current/41001i744.htm

Like Plumb's, it shows interaction information and Gabapentin and Pregablin are NOT mentioned.


ranitidine also gives a reduction of gastric acidity - it also reduces or increases absorption of many drugs, but again Gabapentin and Pregablin are NOT mentioned. Ditto for famotidine and omeprazole.

Nicki
22nd September 2011, 10:08 PM
Could I just remind people of the rules:

While a large degree of latitude is allowed for personal styles of expression, personal attacks, namecalling, and disparagement ...-- singly or collectively -- is not acceptable.


see http://www.cavaliertalk.com/forums/showthread.php?8694-PLEASE-READ-Posting-and-membership-guidelines

Brian M
23rd September 2011, 02:16 PM
Hi

After further professional advice form Daisy's cardio and from many other sources of information and guidance from
many people and including C. R. Sm treatment cascade I have decided that it is not in Daisy' wellbeing to continue with furosemide .I have futher decided not to approach Daisy's neuro for an alternative treatment but I have approached Daisy's vet and requested that he prescribe a change of medication ,I have supplied him with copies of all information to substantiate the reasons for my request and will hopefully have a call back this afternoon .I am
happy with the information I have , and concluded that furosemide should not be administered to a dog with a heart murmur even though Daisy has been diagnosed by full body scan MRI with Sm ,CM and PSOM .We are hopeful that Daisy' vet will prescribe Cimetidine (Zitac ) 50 mg three times daily or possibly consider Ranitidine ,but if not I always have the option of purchasing a generic Cimetidine such as Tagamet over the counter.

Any thoughts please.

Karlin
23rd September 2011, 02:47 PM
Please folks: remember to take personal discussions about identifiable professionals private -- they don't belong on a public board.

Brian said this:


and had better not
spill my inner thoughts and feelings here

And that is where that post and others should leave things -- Brian I am not sure why the decision was then made to then go ahead and make a long post identifying individuals even after this was said by you?

I understand people have frustrations at times with vet care and fully sympathise -- we have ALL been there at one point or another -- but that doesn't mean those frustrations are appropriate to a public board.

Please reread the Getting Started section if anyone is unsure what is OK to post in such situations. These are better conversations to be had amongst yourselves by phone or email, please.

If you are referring to individuals or commenting on someone's post referring to individuals, please contact a moderator or me to see if it is OK to post - or better yet, don't: simply talk privately to those you want an opinion or support from.

Karlin
23rd September 2011, 03:01 PM
On the actual topic: and please ALL further posts are to stay on topic please! :) The issue of frusomide has only very recently arisen because probably SM is one of the ONLY no heart related conditions it has been given for.

As Simon Swift himself indicates: this remains an issue of dispute, and there is not clear agreement even amongst cardiologists. Until Swift mentioned this less than month ago to you Brian, I had never even heard this issue mentioned once. I understand part of the reasoning is that the dose is so small with SM that it is not considered too likely that it would cause issues. I suppose on the realistic side -- sadly there is a higher rate of euthenisation amongst dogs that remain on medications alone for CM/SM as well -- so there would be a question of whether a dog put on this drug for SM is going to live long enough and take enough of it for the heart to be affected. Those are some of the blunt issues we all face in deciding on routes of care with this frustrating, depressing condition.

Likewise there seems a *lot* of dispute over omeprazole. It was very old studies, if I recall, that associate stomach cancer with long term use of this drug and in humans, long term effects meant very long -- dogs live a fraction of the time humans do. I also had read studies that disputed the cancer association. Yet a lot of vets and vet specialists still are uncertain about prescribing omeprazole because of a (disputed?) human cancer risk.

I believe the main reason Clare had moved away from frusemide (at least til recently perhaps?) is not so much the heart concern as just that she feels there are better drugs with fewer side effects. Frusemide causes a lot of excessive urination. She told me recently that she hadn't prescribed it for those reasons in quite a while. Perhaps she has removed it now completely because the jury is out on heart effects and it isn't really necessary to choose frusemide as several meds do the same thing -- inhibit CSF flow.

Different specialists take very different approaches with this condition and any one of them will certainly say there is *no one best approach* so it really makes little sense to berate one approach over another. If someone is unhappy with one approach I'd just get a second opinion/move to a different specialist.

I would NOT leave a dog with CM/SM off neurological care and only rely on a vet -- they do NOT have the expertise around this specialist condition and should not be making treatment decisions! If anyone is unhappy with their specialist, then see another, but please do not leave any dog with this specialist condition without specialist care. :thmbsup:

Brian M
24th September 2011, 11:01 PM
Hi

Guidance please .I know frusomide reduces CSF pressure by the fact it is a diuretic but I thought cimetidine ,or tagamet
is a histamine H2-receptor antagonist that inhibits the production of acid in the stomach and is largely used in the treatment of heartburn and ulcers and I remember my Dad taking them . So how does it act to reduce CSF pressure and is zantac or ranitidine not an improved cimitidine which has no effect on other drugs therefore negating the need to take two hours away from other medication .
Daisy is now on cimetidine 3 x 50 mg prescribed by her vet .During her month on frusemide I dont think I noticed any difference not even in her toileting or increase of water intake so I am wondering how to notice any change now she is on cimetidine as I dont really know what to look for as to me Daisy has always acted and behaved like Daisy always has, apart from the air scartching ,I have no bench mark to work from as she displays no pain or any other sign of SM ,so I am finding it difficult to see any improvement or not ,but as I say I cant see what she has to improve from .I am puzzled .
I appreciate zanatc has no liscence for animals.

Sabby
25th September 2011, 08:43 PM
Hi

Guidance please .I know frusomide reduces CSF pressure by the fact it is a diuretic but I thought cimetidine ,or tagamet
is a histamine H2-receptor antagonist that inhibits the production of acid in the stomach and is largely used in the treatment of heartburn and ulcers and I remember my Dad taking them . So how does it act to reduce CSF pressure and is zantac or ranitidine not an improved cimitidine which has no effect on other drugs therefore negating the need to take two hours away from other medication .
Daisy is now on cimetidine 3 x 50 mg prescribed by her vet .During her month on frusemide I dont think I noticed any difference not even in her toileting or increase of water intake so I am wondering how to notice any change now she is on cimetidine as I dont really know what to look for as to me Daisy has always acted and behaved like Daisy always has, apart from the air scartching ,I have no bench mark to work from as she displays no pain or any other sign of SM ,so I am finding it difficult to see any improvement or not ,but as I say I cant see what she has to improve from .I am puzzled .
I appreciate zanatc has no liscence for animals.

Hi Brian

I have pm'd you with what Clare wrote in Ebony's Report.