Furosemide/Pimobendan Question

All-

Needing some first hand experience stories. Beanie is now on Furosemide and Pimobendan and she drinking enormous amounts of water and then obviously having to go to the bathroom all the time. I know that is one of the Furosemide side effects but when she was just on that it was manageable but since we have added in the Pimobendan, I feel like I have to take her out every hour. She is not sleeping through the night any more either. Is this normal? Could their be something else wrong as well or is this frequent urination and excessive drinking normal with this combination of medications?

No immediate answer here, but I'd give your cardio or vet a call -- whoever prescribed these -- and tell them of this change and get advice. There are alternatives to furosemide -- see a recent thread from Rod on this and also his www.cavalierhealth.org website on MVD. Maybe a different diuretic would be better.

Part of the issue may be that there is more liquid needing to be cleared now and thus she is peeing more but seems very sudden for that.

Have you seen a cardiologist rather than just a vet though? Usually, furosemide is one of the later drugs added to MVD and CHF treatment, not given on its own and never first.

See Rod's site fro treatment approaches: http://www.cavalierhealth.org/mitral_valve_disease.htm#Treatment_

No answer on the furosemide but my dog is on Pimobendan (vetmedin) 1.25mg twice daily and doesn't seem to have any problems with drinking or urination.

We were also told that the Vetmedin would be the first medication and that others like furosemide may need to be added later on if things progress...

pippa said:

... We were also told that the Vetmedin would be the first medication and that others like furosemide may need to be added later on if things progress...

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That is scary advice to me, based upon the fact that the general consensus among cardiologists is that Vetmedin ought to be held in reserve until the dog is in congestive heart failure (CHF), and that Vetmedin can have life-threatening (or worse) side-effects when prescribed for asymptomatic dogs or to dogs which, even though they have enlarged hearts and are in CHF, also still have strong heart muscles and good contractility.

CVFlagg said:

...Could their be something else wrong as well or is this frequent urination and excessive drinking normal with this combination of medications?

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The addition of pimobendan to furosemide is not supposed to result in increased negative side effects. It may be that the furosemide is being made more effective, and that its dosage can be reduced. I would contact the cardiologist's office and ask whether the dosage of furosemide should be reduced, or if another diuretic should be prescribed.

I have a cavalier that has been on Furosemide for 3 years - he has half a 20 mg tablet per day plus he is on Fortekor, I have never known him to drink extra or to urinate more in this time, in fact at times I don`t feel he drinks that much really.

Thank you for all of the input. Yes, she is under the care of a cardiology team at Texas A & M small animal hospital at their vet school. We have a team of five working with us. I am going to email them today and let them know of the new change but it sounds like the adding of the Pimobendan (after the initial signs of CHF appeared) might have increased the effect of the furosemide. We have an appointment to go down there on May 8 but I will go ahead and email them now!

RodRussell said:

That is scary advice to me, based upon the fact that the general consensus among cardiologists is that Vetmedin ought to be held in reserve until the dog is in congestive heart failure (CHF), and that Vetmedin can have life-threatening (or worse) side-effects when prescribed for asymptomatic dogs or to dogs which, even though they have enlarged hearts and are in CHF, also still have strong heart muscles and good contractility.

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Rod, I was just pointing out as Karlin did that Furosemide would not be usually the first drug to give.. With all due respect if you are not a vet or a cardiologist then you can't know what is scary or not in a particular case and Pippin had a full ECG and doppler scan and the vetmedin was prescribed after the results of that not when the murmur was found he has regular check ups with my vet and I also had a long chat with a cardiologist from UCD who looked after my Mum's cat who also has heart problems. Pippin has been on Vetmedin for almost 12 months now and they have helped him to be more active, less lethargic and able to go on short walks without being very breathless. He is doing well and due for check up again in July to see if his murmur has progressed and will have ECG and scans again if needed. If you want to consider this scary advice fine, but I will always do what is best for my dog and I trust my vet and the other vets in the practice that I have attended for years and never had any problems, they have looked after my dogs very well and I am sure they will continue to do so... At the time I had noted that vetmedin is not always given until the dog is in CHF and I discussed all this with my vet as I always do when there is any problem with any of my dogs.

CVFlagg said:

Thank you for all of the input. Yes, she is under the care of a cardiology team at Texas A & M small animal hospital at their vet school. We have a team of five working with us. I am going to email them today and let them know of the new change but it sounds like the adding of the Pimobendan (after the initial signs of CHF appeared) might have increased the effect of the furosemide. We have an appointment to go down there on May 8 but I will go ahead and email them now!

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Sending them an email should help put your mind at rest until your appt in May Let's know how it goes, I hope the problems with thirst and urination settle down for Beanie

pippa said:

Rod, I was just pointing out as Karlin did that Furosemide would not be usually the first drug to give.. With all due respect if you are not a vet or a cardiologist then you can't know what is scary or not in a particular case and Pippin had a full ECG and doppler scan and the vetmedin was prescribed after the results of that not when the murmur was found he has regular check ups with my vet and I also had a long chat with a cardiologist from UCD who looked after my Mum's cat who also has heart problems. Pippin has been on Vetmedin for almost 12 months now and they have helped him to be more active, less lethargic and able to go on short walks without being very breathless. He is doing well and due for check up again in July to see if his murmur has progressed and will have ECG and scans again if needed. If you want to consider this scary advice fine, but I will always do what is best for my dog and I trust my vet and the other vets in the practice that I have attended for years and never had any problems, they have looked after my dogs very well and I am sure they will continue to do so... At the time I had noted that vetmedin is not always given until the dog is in CHF and I discussed all this with my vet as I always do when there is any problem with any of my dogs.

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I had a cavalier that nearly died because of the pre-mature prescription of pimo, after a full cardiology exam. So, I have taken particular interest in if and when pimo should be prescribed. Based upon what I know about pimo, and what I've read about it, it is scary to me to administer it prior to CHF, and in some cases, even when the dog is in CHF. That cavalier of mine was in CHF when he began taking pimo, and because it over-strengthened his heart's contractility, it nearly killed him. We started reducing his dosage within a day, and then we had to stop it altogether.

I am of course very sorry to hear what happened to your cavalier and must have been a terribly scary thing to have to deal with, but I have read up on this and actually contacted the suppliers of vetmedin in the UK so please understand that I don't just do what the vet says because she/he is a vet. (I'm the same myself with doctors)

As I said Pippin is monitored well his heart is stable at the moment and I keep a close watch for any changes in him, maybe too much sometimes I think every case is different though and should be treated as so.

pippa said:

I am of course very sorry to hear what happened to your cavalier and must have been a terribly scary thing to have to deal with, but I have read up on this and actually contacted the suppliers of vetmedin in the UK so please understand that I don't just do what the vet says because she/he is a vet. (I'm the same myself with doctors) ...

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I meant to add to my previous post that in the United States, the U.S. Food and Drug Administration’s (FDA) 2007 report approving the use of pimobendan for dogs also contained the warning that the drug not be prescribed by dogs which are not in congestive heart failure. On each container of Vetmedin is the warning that “Vetmedin should not be given in cases ... where an augmentation of cardiac output is inappropriate for functional or anatomical reasons. Warnings: Only for use in dogs with clinical evidence of heart failure.”

As for consulting with the manufacturer of Vetmedin, I have found that in the US, their marketing representatives are notorious for lying about when the drug should be started. I have no faith whatsoever in the honesty of what that company has to say about using Vetmedin.

Think we'll have to agree to disagree on this one Rod, I have to do what I feel is right for Pippin

Back to the original question, there is more information than was included in first post - look at this thread:

http://www.cavaliertalk.com/forums/showthread.php?41042-Beanie-s-MVD

I presume that Beanie is still taking enalapril, amlodipine and a bronchodilator. (By the way, I've never had a dog that was able to tolerate a bronchodilator because of the side effects of agitation, trembling, etc.) Furosemide was not started as the first drug, and it is standard to start this diuretic as soon as heart failure ensues. There is not a good alternative for this loop diuretic, but the dosage may be able to be lowered with the other drugs in the mix, or they may choose to add spironolactone, etc., and try to lower the furosemide dosage. What exactly has happened since your March 14th post - more details would be helpful.

I've found that timing is key when using furosemide - peak action after oral administration is 30 minutes to two hours. I would give it and let the dog out about 30-45 minutes later and then again at two hours after, and then I found that a dog would be okay for six hours or more. How much does Beanie weigh and what is the dosage? What times of day/night are you giving the furosemide? When did you last run blood chemistry and urinalysis after starting the drug? (Checking kidney function and electrolytes.) I also train my seniors with chronic illnesses and on meds to use potty pads, and they've all caught on quickly - need to make sure that a senior, ill dog always is able to urinate when necessary and always has access to water. I use the pooch pads which are washable, and I like them so much better than the flimsy disposable pads. (poochpads.com)

More information would be helpful in giving a better answer.

Pat

Hi Pat-

As always, thank you for your thorough response! Yes, Beanie is still on enalapril, amlodopine and turbutaline (broncho), she is currently 17lbs. She did not do well on the first bronchodilator at all but since the switch to the turbutaline the tremors and twitching has ceased. We got to the point of adding the furosemide after I heard back from the cardiologist on the set of x-rays on March 13. The team at A&M saw a collection of fluids and made the decision to begin the furosemide. Then, when I called for refills (they only gave me a small amount to test first) they had us do another set of x-rays and complete blood panel/urinalysis on 3/28 before refilling and they noticed that the heart had continued to enlarge and there was "a singular interloberlor pleural fissure line between the right cranial and middle lung lobes. And there is some prominence of the left a recure appendage which was not previously noted." So, then they decided to start the pimobendan. Because she has EPI too, we check her urine pretty regularly to make sure diabetes has not developed (lord help me if it does!).

I spoke with the cardiologist this morning and he wants me to track her urination and water consumption but he believes it is completely inline with the side effects of the furosemide, and that I am just not used to it yet (she has been on all those meds for a week and I was out of town for three of the days). He also mentioned having water available at all time so I have added a bowl to my bathroom for when she is in my bedroom with me.

Thank you for the information on the timing of giving the drugs. I was giving her the nighttime dose right before bed, so that could have been part of my problem. Gave it at dinner time tonight and left the back door open for her to go out and no accidents yet. Below is everything she is on with dosages. I so appreciate everyone's help and support. The dogs I have now (4 cavaliers) are the first dogs I have ever had in my entire life so Beanie could be the first one I ever lose and it totally terrifies me!

- Terbutaline, 2.5 mg- 1/2 tab 2x day
- Pimobendan, 5mg- 1/2 tab 2x day
- Amlodapine, 1.25ml- 2x day (we had this compounded)
- Enalapril, 2.5mg- 1 tab 2x day
- Furosemide, 12.5mg- 1 tab 2x day