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Madeline -- Heart issues/hyperthyroid/possible inflammatory bowel...

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  • Cathryn
    My cat Madeline recently had an episode of panting with her mouth open - on the way to the vet, it stopped (This was Monday night 5/31). She went to have an
    Message 1 of 5 , Jun 4, 2010
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      My cat Madeline recently had an episode of panting with her mouth open - on
      the way to the vet, it stopped (This was Monday night 5/31). She went to
      have an echo cardiogram, ecg, and abdominal ultrasound on wednesday 6/2.
      Cardiologist prescribed lasik, benazepril, and plavix -- more detail
      outlined below. On the Whole Cat Health list (so great) they suggested
      nattokinase. I am wondering about the other heart drugs. I'm a little
      worried about the lasik and kidney but maybe she needs it. She is pretty
      lethargic right now tho' and I want to help her feel better. I just started
      feeding her novel protein diet in case she does have inflammatory bowel to
      address that. I've given a lot of the background BELOW in addition to the
      heart information but that's what I'm trying to address since it seems most
      important (tho' there could be other factors).

      Many thanks - Cathryn.

      This is some of her past history:

      MADELINE :

      Madeline is a lovely calico female cat who had hyperthyroid diagnosed about
      a year and a half or so ago. I thought she was about 8 years old, found on
      the street at about 1 1/2 years, the vets think she may be older than this
      (10-11-more?). Her teeth were bad a few years ago - right now she has an
      abscessed tooth. It was determined she had Bartonella a few years ago but it
      was never fully treated. She is about 4.7 pounds now but was 6 pounds in the
      fall.

      She has a complicated medical history but basically what is going on right
      now is:

      VET VISIT FRIDAY 5/29/10

      She wasn�t drinking water or eating much Thursday - just sitting by the
      water bowl lingering but not drinking - so I brought her to the vet on
      Friday 5/30. They gave her subcutaneous fluids, B12 shot, pepcid.

      Her other current conditions/symptoms are: loopy thickened intestines (she
      has had this for a long time now), sometimes un-symptomatic urinary tract
      infection, bad teeth (one of them is abscessed), lost weight, bartonella (I
      assume that is still current).

      She was on Tapazole 1/4 tablet 1 x (1.25 mg) a day from about the fall 2009
      to March - when she started losing weight the doctor put her on 2 x a day
      1/4 tablet (1.25 mg 2 x a day).

      The new vet who saw her last Friday thought her intestines were so thickened
      that something else might be going on there. Also because of her heart rate
      she was concerned about heart disease. She also was worried about her
      kidneys but more so the first two at that time - inflammatory bowel and
      heart.

      BLOOD WORK (kidney values) Friday 5/29:

      AST 38 U/L (range 10-100)
      ALT 117 U/L (range 10-100) HIGH
      Urea Nitrogen 42 mg/dl (range 14-36) HIGH
      Creatinine 1.3 mg/dl (range .6-2.4)
      Alkaline Phosphatase 67 (range 6-102 u/l)
      GGTP ,5 u/l (range 1-10)
      phosphorus 5.2 (range 2.4-8.2)

      PREVIOUS THYROID T4: The last thyroid result was in March 2010 : T4 3.7 (
      range .5 - 4.7) The thyroid was rechecked on wednesday - I don't have #'s
      yet.

      SEPTEMBER 2009 & 5/29/10 URINE:

      In September her urine was checked and she had concentrated urine; SP
      Gravity (I believe that�s the value) was 10.27; now (5/29) it is 10.20. The
      doctor on Friday could not do a culture to check for UTI, etc. because there
      was not enough urine present. In September 2009, she also had a UTI (no
      symptoms) so the doctor was not that concerned about that #. The UTI most
      likely didn�t clear entirely from the antibiotic treatment (not long enough)
      earlier that year.

      MEDICINE PRESCRIBED 5/29:

      The vet on Friday 5/29 prescribed for her Clavamox liquid .5 ml (for dental
      infection and if UTI is present) to take 2 x a day; Atenolol 1/4 tablet 1 x
      a day and continue Tapazol 1/4 tablet 2 x a day. She also prescribed
      Budesonide (steroid) because of the inflammatory bowel. I did not ever give
      her the Budesonide and I gave her Atenolol 2 x (1 for 2 days) before the
      open breathing incident Monday night and then stopped and went to
      cardiologist Wednesday. Initially, I just didn't feel I could spend more
      money and so the vet was trying to help her somewhat but suggested in future
      echo cardiogram and abdominal ultrasound. (Then when she had the open
      breathing incident I had her fully tested.)

      Monday night 5/31, we went to the emergency clinic because she was breathing
      - panting with her mouth open and tongue out and a bit of drool was coming
      from her mouth. Mid way there in the car, she stopped panting and was fine
      but based on her history the vet wanted to take an xray to see her lungs and
      heart.

      Her temperature was 99.9. Heart beat (I believe? it should be 140-160) was
      200. Respiratory rate was 60.

      I took her off the Clavamox because I gave it to her Wednesday night and her
      mood just changed shortly after. She seemed more lethargic and I was really
      worried about her.

      MOST RECENT WEDNESDAY, JUNE 2ND: Cardiologist/Internal Medicine doctor
      Visit:

      This is a combination of my notes and notes the cardiologist typed up -- We
      saw two doctors the cardiologist and an internal medicine doctor who did the
      ultrasound.

      BLOOD WORK: They checked her thyroid but I don't have what the levels were
      yet.

      ECHOCARDIOGRAM, ECG, BLOOD PRESSURE:

      Madeline has a gallup rhythm - too thick heart muscle. She has a thick left
      ventricle and her left and right atria are enlarged.

      His notes: "There is severe generalized cardiomegaly and biatrial
      enlargement. There is mild pulmonary venous distention and a 1.5 x 1.6
      unstructured soft tissue opacity within the left caudal lung field."

      "On physical exam a gallop rhythm was heart. Her lungs were hard, and a
      large thyroid was felt. Her intestinal loops are palpated thick. Her blood
      pressure was 170 mmHg (mildly elevated), and she had a few intermittent
      premature ventricular complexes during the echo. Her echocardiagram revealed
      severe thickening of her left ventricular posterior wall, and severe
      enlargement of both of her atria. there was also evidence of swirling blood
      flow in her atrium to suggest a clot is possible. These changes may be due
      in part due to uncontrolled hyperthyroidism, but likely represent at some
      some component of hypertrophic cardiomyopathy. A blood clot or mild fluid
      accumulation within the lungs may be the cause of the previous clinical
      signs." (cathryn: meaning panting on monday night.)

      "Hypertropic cardiomyopathy is likely a genetic disease that has caused
      significant thickening of the heart muscle. At this time, there is
      significant thickening to the ventricle and advanced disease which has led
      to fluid buildup (congestive heart failure)."

      EKG was okay.

      ABDOMINAL ULTRASOUND:

      "The ultrasound showed large lymph nodes, an abnormal liver/spleen and fluid
      buildup in the abdomen possible suggestive of cancer."

      The doctor told me her intestines are thickened larger than 1/2 cm (which is
      a normal size) and large which could be IBD or lymphoma.

      No distinctive mass.

      Lymph nodes enlarged.

      Pancreas visible. Possible previous pancreatitis. Doesn't have now.

      Liver and spleen "abnormal" meaning big - also could be IBD or cancer.

      OVERVIEW TREATMENT:

      "Treatment is aimed at reducing blood volume (diuretics), easing workload on
      the heart, and prevent blood clots with anti-thrombotic medication. Response
      to treatment is variable, but often patients can live for several months to
      even a year or more on medical therapy, providing there is a good response
      initially and the kidneys can tolerate the therapy. However, there will be
      risk for recurrent heart failure, blood clots and even sudden death despite
      treatment."

      Internal medicine doctor recommended a # of options:
      1. do nothing but cardiologist recommendations (as far as IBD or cancer
      diagnosis),
      2. sterioids but concern how they may affect the heart. could decrease
      inflammation if IBD and also cancer.
      3. aspirates of liver, spleen, lymph nodes.

      She didn't think her other options 4 & 5 were viable since they required
      anesthesia and I'm not considering them: they were
      4. encoscopy (camera into gi tract with biopsy of aspirated) 5. surgery
      with biopsies of everything.

      I mentioned continuing B12 shots (other vet suggested every 2 weeks for 6
      weeks) and novel protein diet. She said that was fine could work if it's
      IBD, would take 6 weeks to know. She said to check back with her in 1 week
      with how I want to proceed.

      MEDICATION:

      Cardiologist recommended the following:

      *Lasix elixir: 10 mg/ml give .2 cc by mouth every 24 hours (for those
      like me who don't know this is a diuretic)

      *Benazepril: 5 mg. give 1/4 tablet by mouth every 24 hours (this is an
      ace inhibitor)

      *Plavix 75 mg : Give 1/4 tablet every 24 hours.

      He said Plavix is very expensive ($10 a tablet) so aspirin every 72 hours -
      not sure of dosage, he said to discuss with him - would be recommended.

      FOLLOWUP:

      GET BLOOD WORK rechecked in 1 week with regular vet. Repeat chest x-rays in
      2 months.


      ******************************


      I know it's a lot to take in. I think that's 'it.' Thanks very much.

      Cathryn.


      [Non-text portions of this message have been removed]
    • Westgold
      hi -- I m sorry to hear about your little kitty. This is a most thorough examination she had. DO NOT LET ANYBODY GIVE HER STEROIDS FOR ANY REASON. There is
      Message 2 of 5 , Jun 4, 2010
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        hi -- I'm sorry to hear about your little kitty. This is a most thorough examination she had. DO NOT LET ANYBODY GIVE HER STEROIDS FOR ANY REASON. There is always an alternative. Steriods could send her over the edge immediately. Steriods should NEVER EVER be given to a kitty with HCM. The other meds seem standard. But please do not listen to any timeline you are given. I hate it when vets give timelines. They can't possibly know. We have kitties on this list alive and kicking YEARS after their vets said they'd be gone.

        Since Madeline has several things wrong with her, you'll have to work closely with the cardiologist to carefully coordinate all her meds, etc. You may be able to get some of them compounded into a liquid form that can be mixed with the food, so you don't have to give her too many pills. But once that is worked out, she could keep going for years. Just keep an eye on her values regularly. The most urgent problem with now is probably the extra fluid, but the lasix will help with that. You have to keep an eye on her breathing rate -- *resting* breaths per minute should be around 23-27. If they go to over 40, or there is open-mouthed or deep labored breathing, that's an emergency and she needs to be taken in immediately so they can clear the fluid from her lungs manually. Sometimes the lasix by itself isn't enough. Others can give you more info on that, my heart kitty hasn't had any fluid problems yet.

        Please keep us postedm, and let us know if there's anything else we can do to help. Among us, we've been through just about everything!

        take care -- Michelle & Tigger Too in Toronto



        [Non-text portions of this message have been removed]
      • Cathryn
        Hi Michelle, Thanks so much for this note. Great to hear your experiences and I hear what you are saying about the steroids. That would have been bad. So I
        Message 3 of 5 , Jun 4, 2010
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          Hi Michelle,

          Thanks so much for this note. Great to hear your experiences and I hear what
          you are saying about the steroids. That would have been bad. So I was
          reading up on Lasix and came across this page that said the following about
          furosemide. Madeline was prescribed furosemide and benazepril at the same
          time. This says to wait before adding in the benazepril. The cardiologist
          isn't in today tho' I gather he'd say it's okay. (Sometimes reading up on
          this can make one nervous for sure!)

          What do you think?

          Thanks.

          Cathryn.


          From: http://www.marvistavet.com/html/body_furosemide.html

          INTERACTIONS WITH OTHER DRUGS

          One of the most common drug interactions to be aware of is the interaction
          between furosemide and vasodilating heart medications (especially the
          Angiotensin Converting Enzyme inhibitors such as
          enalapril<http://www.marvistavet.com/html/body_enalapril.html>,
          benazepril <http://www.marvistavet.com/html/body_benazepril.html>, and
          lisinopril). Furosemide will decrease circulating blood volume as it causes
          a depletion in body water. This means that the kidney (and most other
          organs) will have a reduced blood flow to them. The patient�s kidney and
          electrolyte balance must stabilize before a vasodilator is added in. If the
          vasodilator is added too soon, it too will reduce blood flow to the kidney
          and the kidney will fail, possibly permanently. *These medications are
          frequently used together in heart failure patients. To avoid problems, the
          patient should be assessed biochemically with a blood test prior to the
          addition of the vasodilator. If all is normal, the vasodilator may be
          started and renal blood parameters should be rechecked 3-5 days later. If
          they are still normal, then the above kidney issues should not be a problem;
          however, should another heart failure crisis arise and large doses of
          injectable lasix be required to resolve it, kidney values should again be
          checked 3-5 days later.*

          The airway dilator theophylline may be able to reach higher blood levels
          when used in conjunction with furosemide. This means that the theophylline
          dose may need to be reduced.

          Furosemide is often used concurrently with digitalis derivatives. If
          furosemide leads to a significant drop in blood potassium levels, this can
          increase the risk of heart rhythms disturbances and other signs of digitalis
          toxicity.

          Furosemide is often used in combination with
          prednisone<http://www.marvistavet.com/html/body_prednisone.html>to
          reduce serum calcium levels. It is possible for this combination of
          medication to lead to a reduction in potassium level significant enough to
          require potassium supplementation.

          Aminoglycoside antibiotics (amikacin, gentamicin etc.) have properties that
          make them toxic to the ear and to the kidney. These properties increase with
          concomitant use of furosemide.

          CONCERNS AND CAUTIONS

          Obviously it is best not to use this medication in a dehydrated patient if
          water is being restricted.

          Weakness or lethargy could be an indicator that blood potassium has dropped
          too low. Be sure to inform your veterinarian if your pet seems listless.

          Because of the increased calcium excretion brought on by furosemide (i.e. an
          increase in urinary calcium levels), there could be a problem using this
          medication in patients with a history of calcium oxalate bladder
          stone<http://www.marvistavet.com/html/canine_oxalate_bladder_stones.html>formation.

          *It is extremely difficult to overdose with this medication. Toxic doses
          reported are over 100 times a typical oral dose of medication. It is
          important to realize that in the treatment of heart failure (this drug�s
          primary use), a crisis can arise at any time. Often giving an extra dose of
          oral medication can be a life saving procedure. Be sure you understand what
          signs you are to watch for to determine if an extra dose or two should be
          administered and when you should definitely rush to the vet�s office.*

          The loss of water-soluble vitamins or urine can be a problem for patients
          receiving diuretics. Prescription diets for heart and kidney disease are
          vitamin-fortified with these extra losses in mind. Patients that refuse to
          eat such prescription diets should probably receive a vitamin supplement.




          On Fri, Jun 4, 2010 at 2:04 PM, Westgold <westgold@...> wrote:

          > *hi -- I'm sorry to hear about your little kitty. This is a
          > most thorough examination she had. DO NOT LET ANYBODY GIVE HER STEROIDS FOR
          > ANY REASON. There is always an alternative. Steriods could send her over
          > the edge immediately. Steriods should NEVER EVER be given to a kitty with
          > HCM. The other meds seem standard. But please do not listen to any
          > timeline you are given. I hate it when vets give timelines. They can't
          > possibly know. We have kitties on this list alive and kicking YEARS after
          > their vets said they'd be gone. *
          > **
          > *Since Madeline has several things wrong with her, you'll have to work
          > closely with the cardiologist to carefully coordinate all her meds, etc.
          > You may be able to get some of them compounded into a liquid form that can
          > be mixed with the food, so you don't have to give her too many pills. But
          > once that is worked out, she could keep going for years. Just keep an eye
          > on her values regularly. The most urgent problem with now is probably the
          > extra fluid, but the lasix will help with that. You have to keep an eye on
          > her breathing rate -- *resting* breaths per minute should be around 23-27.
          > If they go to over 40, or there is open-mouthed or deep labored breathing,
          > that's an emergency and she needs to be taken in immediately so they can
          > clear the fluid from her lungs manually. Sometimes the lasix by itself
          > isn't enough. Others can give you more info on that, my heart kitty hasn't
          > had any fluid problems yet.*
          > **
          > *Please keep us postedm, and let us know if there's anything else we can
          > do to help. Among us, we've been through just about everything!*
          > **
          > *take care -- Michelle & Tigger Too in Toronto*
          > **
          > **
          >


          [Non-text portions of this message have been removed]
        • Westgold
          oh, yeah -- there s a lot of really scary stuff out there! And the more research you do, the scarier it gets!! But your best friend right now is Madeline s
          Message 4 of 5 , Jun 4, 2010
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            oh, yeah -- there's a lot of really scary stuff out there! And the more research you do, the scarier it gets!! But your best friend right now is Madeline's cardiologist.

            Why don't you ask on the list -- if others were given lasix & benazepril at the same time, and if it was ok, etc. She may also need potassium supplements, as the lasix washes it away. This is why you need to work closely with your cardiologist, to keep on top of everything. Tigger has mild HCM, and is just on atenolol (over 5 years now). So I don't have experience with anything else.

            Cathryn, all we can do is what we can do, and hope and pray for the best. Madeline is so blessed to have someone as caring as you to take care of her. Just do what you can do, and leave the rest to God. HCM is horrible, and it can turn on a dime. Even if you do everything right, we still have to be prepared that they could go at any minute. My vet has the philosophy that kitties are "here for a good time, not a long time -- so have a good time, the sun don't shine everyday". He's right. We need to enjoy every precious minute we have with our little ones.

            take care -- Michelle & Tigger Too in Toronto
            ----- Original Message -----
            From: Cathryn
            To: Westgold ; feline-heart@yahoogroups.com
            Sent: Friday, June 04, 2010 2:15 PM
            Subject: Re: [FH] Madeline -- Heart issues/hyperthyroid/possible inflammatory bowel...


            Hi Michelle,

            Thanks so much for this note. Great to hear your experiences and I hear what you are saying about the steroids. That would have been bad. So I was reading up on Lasix and came across this page that said the following about furosemide. Madeline was prescribed furosemide and benazepril at the same time. This says to wait before adding in the benazepril. The cardiologist isn't in today tho' I gather he'd say it's okay. (Sometimes reading up on this can make one nervous for sure!)

            What do you think?

            Thanks.

            Cathryn.


            From: http://www.marvistavet.com/html/body_furosemide.html

            INTERACTIONS WITH OTHER DRUGS

            One of the most common drug interactions to be aware of is the interaction between furosemide and vasodilating heart medications (especially the Angiotensin Converting Enzyme inhibitors such as enalapril, benazepril, and lisinopril). Furosemide will decrease circulating blood volume as it causes a depletion in body water. This means that the kidney (and most other organs) will have a reduced blood flow to them. The patient�s kidney and electrolyte balance must stabilize before a vasodilator is added in. If the vasodilator is added too soon, it too will reduce blood flow to the kidney and the kidney will fail, possibly permanently. These medications are frequently used together in heart failure patients. To avoid problems, the patient should be assessed biochemically with a blood test prior to the addition of the vasodilator. If all is normal, the vasodilator may be started and renal blood parameters should be rechecked 3-5 days later. If they are still normal, then the above kidney issues should not be a problem; however, should another heart failure crisis arise and large doses of injectable lasix be required to resolve it, kidney values should again be checked 3-5 days later.

            The airway dilator theophylline may be able to reach higher blood levels when used in conjunction with furosemide. This means that the theophylline dose may need to be reduced.

            Furosemide is often used concurrently with digitalis derivatives. If furosemide leads to a significant drop in blood potassium levels, this can increase the risk of heart rhythms disturbances and other signs of digitalis toxicity.

            Furosemide is often used in combination with prednisone to reduce serum calcium levels. It is possible for this combination of medication to lead to a reduction in potassium level significant enough to require potassium supplementation.

            Aminoglycoside antibiotics (amikacin, gentamicin etc.) have properties that make them toxic to the ear and to the kidney. These properties increase with concomitant use of furosemide.

            CONCERNS AND CAUTIONS

            Obviously it is best not to use this medication in a dehydrated patient if water is being restricted.

            Weakness or lethargy could be an indicator that blood potassium has dropped too low. Be sure to inform your veterinarian if your pet seems listless.

            Because of the increased calcium excretion brought on by furosemide (i.e. an increase in urinary calcium levels), there could be a problem using this medication in patients with a history of calcium oxalate bladder stone formation.

            It is extremely difficult to overdose with this medication. Toxic doses reported are over 100 times a typical oral dose of medication. It is important to realize that in the treatment of heart failure (this drug�s primary use), a crisis can arise at any time. Often giving an extra dose of oral medication can be a life saving procedure. Be sure you understand what signs you are to watch for to determine if an extra dose or two should be administered and when you should definitely rush to the vet�s office.

            The loss of water-soluble vitamins or urine can be a problem for patients receiving diuretics. Prescription diets for heart and kidney disease are vitamin-fortified with these extra losses in mind. Patients that refuse to eat such prescription diets should probably receive a vitamin supplement.




            [Non-text portions of this message have been removed]
          • Cathryn
            Hi Michelle, Yes I m posting to the list as well. The cardiologist is not reachable right now unfortunately but one of the other doctors is trying to reach
            Message 5 of 5 , Jun 4, 2010
            • 0 Attachment
              Hi Michelle,

              Yes I'm posting to the list as well.

              The cardiologist is not reachable right now unfortunately but one of the
              other doctors is trying to reach him.

              You have a good attitude about it. Thank you!!

              I just found out that Madeline's hyperthyroid T4 # is now at 6 which is way
              higher than we anticipated.

              Thank you --

              Cathryn.

              On Fri, Jun 4, 2010 at 2:28 PM, Westgold <westgold@...> wrote:

              > *oh, yeah -- there's a lot of really scary stuff out there! And the more
              > research you do, the scarier it gets!! But your best friend right now is
              > Madeline's cardiologist. *
              >
              > *Why don't you ask on the list -- if others were given lasix & benazepril
              > at the same time, and if it was ok, etc. She may also need potassium
              > supplements, as the lasix washes it away. This is why you need to work
              > closely with your cardiologist, to keep on top of everything. Tigger has
              > mild HCM, and is just on atenolol (over 5 years now). So I don't have
              > experience with anything else. *
              > ****
              > *Cathryn, all we can do is what we can do, and hope and pray for the
              > best. Madeline is so blessed to have someone as caring as you to take care
              > of her. Just do what you can do, and leave the rest to God. HCM is
              > horrible, and it can turn on a dime. Even if you do everything right, we
              > still have to be prepared that they could go at any minute. My vet has the
              > philosophy that kitties are "here for a good time, not a long time -- so
              > have a good time, the sun don't shine everyday". He's right. We need to
              > enjoy every precious minute we have with our little ones. *
              > **
              > *take care -- Michelle & Tigger Too in Toronto*
              >
              > ----- Original Message -----
              > *From:* Cathryn <cathryn.be@...>
              > *To:* Westgold <westgold@...> ; feline-heart@yahoogroups.com
              > *Sent:* Friday, June 04, 2010 2:15 PM
              > *Subject:* Re: [FH] Madeline -- Heart issues/hyperthyroid/possible
              > inflammatory bowel...
              >
              > Hi Michelle,
              >
              > Thanks so much for this note. Great to hear your experiences and I hear
              > what you are saying about the steroids. That would have been bad. So I was
              > reading up on Lasix and came across this page that said the following about
              > furosemide. Madeline was prescribed furosemide and benazepril at the same
              > time. This says to wait before adding in the benazepril. The cardiologist
              > isn't in today tho' I gather he'd say it's okay. (Sometimes reading up on
              > this can make one nervous for sure!)
              >
              > What do you think?
              >
              > Thanks.
              >
              > Cathryn.
              >
              >
              > From: http://www.marvistavet.com/html/body_furosemide.html
              >
              > INTERACTIONS WITH OTHER DRUGS
              >
              > One of the most common drug interactions to be aware of is the interaction
              > between furosemide and vasodilating heart medications (especially the
              > Angiotensin Converting Enzyme inhibitors such as enalapril<http://www.marvistavet.com/html/body_enalapril.html>,
              > benazepril <http://www.marvistavet.com/html/body_benazepril.html>, and
              > lisinopril). Furosemide will decrease circulating blood volume as it causes
              > a depletion in body water. This means that the kidney (and most other
              > organs) will have a reduced blood flow to them. The patient�s kidney and
              > electrolyte balance must stabilize before a vasodilator is added in. If the
              > vasodilator is added too soon, it too will reduce blood flow to the kidney
              > and the kidney will fail, possibly permanently. *These medications are
              > frequently used together in heart failure patients. To avoid problems, the
              > patient should be assessed biochemically with a blood test prior to the
              > addition of the vasodilator. If all is normal, the vasodilator may be
              > started and renal blood parameters should be rechecked 3-5 days later. If
              > they are still normal, then the above kidney issues should not be a problem;
              > however, should another heart failure crisis arise and large doses of
              > injectable lasix be required to resolve it, kidney values should again be
              > checked 3-5 days later.*
              >
              > The airway dilator theophylline may be able to reach higher blood levels
              > when used in conjunction with furosemide. This means that the theophylline
              > dose may need to be reduced.
              >
              > Furosemide is often used concurrently with digitalis derivatives. If
              > furosemide leads to a significant drop in blood potassium levels, this can
              > increase the risk of heart rhythms disturbances and other signs of digitalis
              > toxicity.
              >
              > Furosemide is often used in combination with prednisone<http://www.marvistavet.com/html/body_prednisone.html>to reduce serum calcium levels. It is possible for this combination of
              > medication to lead to a reduction in potassium level significant enough to
              > require potassium supplementation.
              >
              > Aminoglycoside antibiotics (amikacin, gentamicin etc.) have properties that
              > make them toxic to the ear and to the kidney. These properties increase with
              > concomitant use of furosemide.
              >
              > CONCERNS AND CAUTIONS
              >
              > Obviously it is best not to use this medication in a dehydrated patient if
              > water is being restricted.
              >
              > Weakness or lethargy could be an indicator that blood potassium has dropped
              > too low. Be sure to inform your veterinarian if your pet seems listless.
              >
              > Because of the increased calcium excretion brought on by furosemide (i.e.
              > an increase in urinary calcium levels), there could be a problem using this
              > medication in patients with a history of calcium oxalate bladder stone<http://www.marvistavet.com/html/canine_oxalate_bladder_stones.html>formation.
              >
              > *It is extremely difficult to overdose with this medication. Toxic doses
              > reported are over 100 times a typical oral dose of medication. It is
              > important to realize that in the treatment of heart failure (this drug�s
              > primary use), a crisis can arise at any time. Often giving an extra dose of
              > oral medication can be a life saving procedure. Be sure you understand what
              > signs you are to watch for to determine if an extra dose or two should be
              > administered and when you should definitely rush to the vet�s office.*
              >
              > The loss of water-soluble vitamins or urine can be a problem for patients
              > receiving diuretics. Prescription diets for heart and kidney disease are
              > vitamin-fortified with these extra losses in mind. Patients that refuse to
              > eat such prescription diets should probably receive a vitamin supplement.
              >
              >


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