ACE inhibitors and anemia

Discussion in 'Feline Health - (Welcome & Main Forum)' started by Linda and Bear Man, Jun 7, 2010.

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  1. Linda and Bear Man

    Linda and Bear Man Well-Known Member

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    Dec 28, 2009
    I am wondering if anyone has any knowledge of, or experience with, ACE inhibitors (i.e. benazepril/fortekor/lotensin) causing or exacerbating anemia. I have found one article online that discusses this. Bear Man has multiple health issues: anemia, severe IBD, CP, CRF, hypertension, chronic pyelonephritis (which can cause anemia), cushings, etc. He takes multiple meds, including methimazole (which I understand can also be associated with anemia) and steroids. He chronically has large amounts of blood and protein in his urine. He takes amlodipine for hypertension, as well as benazepril, which was started after some positive UPCR tests. His recent bloodwork, done after I noted pallor, lethargy and weakness, shows a worsening of his anemia. The vet feels that his anemia is multifactorial: kidney disease affecting production of erythropoietin, blood loss through his kidneys, and blood loss through his GI system. After I came across the association of ACE inhibitors and anemia, I asked the vet if we should discontinue the benazepril, and she agreed it was worth a try. I don't know if it is more important to have the benazepril on board to help his kidneys, or if it truly is one of the many factors causing his anemia. All things Bear-related involve delicate balancing acts. I would appreciate any thoughts on this.

    Hematocrit: .21 (ref .24 - .45)
    RBC 4.9 (ref 6.0 - 11.0)
    Hemoglobin: 60 (ref 80 - 150)
     
  2. Pandasmom

    Pandasmom Member

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    Feb 16, 2010
    I have no answers for you, I just wanted to say - wow, that's quite the juggling act.
    I'm having to juggle a lot with Odie too, but this seems even more complicated.

    Good luck in getting something worked out, I know it's frustrating.

    Odiesmom
     
  3. Jess & Earl

    Jess & Earl Member

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    Dec 28, 2009
    Hi Linda

    I'm sorry to hear that Bear is having trouble :( I have not heard of any association between benazepril and anemia. Did the article you found mention benazepril or another ACE inhibitor? Rarely, humans will have an immune reaction to some of the ACE inhibitors (like captopril, but not benazepril) but this has not been reported in cats. ACE inhibitors have been proven to extend life in cats with protein-losing renal disease, so I'd be hesitant to stop it.

    Does your vet feel it's time to consider darbepoetin? Is the anemia regenerative? Have you considered a bone marrow aspirate?
     
  4. Linda and Bear Man

    Linda and Bear Man Well-Known Member

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    Dec 28, 2009
    Hi Jess
    Thank you for your response. It was Tanya's CRF site that linked me to this paper: http://ndt.oxfordjournals.org/cgi/conte ... /14/8/1836. It doesn't mention Benazepril specifically. My vet also found something on VIN by Marathias KP, Agroyannis B, Mavromoustakos T, Matsoukas J, Vlahakos DV.

    Darbopoetin? We talked about Epogen. She said she usually starts it at a lower hematocrit - around .16 I think she said - but she is concerned about giving it to Bear as he is ultra sensitive to drugs, and it may make his anemia worse. She is also looking into transfusions, but her initial thoughts were that the transfused cells only last for days.

    I have not considered a bone marrow aspirate. What would that tell me? He cannot possibly tolerate anesthesia in his condition. I don't know if his anemia is regenerative. How would I know? She says he is partly not producing enough erythropoietin, and partly losing blood from his kidneys and gut.

    I'm sorry that I am not well educated or well read enough on the topic to answer your questions more intelligently. I thank you for your help. It sounds like I should be putting him back on it; however, to look at him weak and lethargic, and with ears white as a ghost, it looks like I am more likely to lose him from anemia, and soon. His dropping numbers are scaring me, and so is his clinical presentation.
     
  5. WCF and Meowzi

    WCF and Meowzi Well-Known Member

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    Dec 28, 2009
    darbepoetin is also known as aranesp, you may have come across that name.

    see reticulocytes on tanya's site.

    (((linda))) (((bear)))
     
  6. laur+danny+horde

    laur+danny+horde Member

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    Dec 29, 2009
    no info or suggestions for you, just hugs. I hope your Bear Man feels better soon but I know you must be very worried.

    (((Linda)))
     
  7. Jess & Earl

    Jess & Earl Member

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    Dec 28, 2009
    This is interesting, thanks for sharing.
    Darbepoetin is similar to Epogen but is preferred by some specialists who feel that it may cause fewer reactions than Epogen. It used to be prohibitively expensive, but is now supposed to be around the same price as Epogen.

    The greatest danger with giving a synthetic erythropoetin drug like darbe or epo is that the cat will recognize it as foreign and attack it, and will inadvertently destroy its *own* native erythropoetin. If this happens, the cat basically becomes transfusion dependent. Pretty scary. BUT, this only happens in a minority of cats. In Earl's case, I used it only when I knew we were out of reasonable options. His PCV was 20%, I couldn't lower his pred dose, I knew he had cancer(s) and renal disease. His PCV held steady for a while but then he had complications from his other diseases so I won't know if it really worked.

    You can certainly try stopping the benazepril. But if he is:

    it sounds like he might be in darbe/Epo territory, or transfusion territory, if he is symptomatic for his anemia. Cats with anemia can get a very fast heart rate as their heart works overtime to try to deliver oxygen all over the body. (The red blood cells carry oxygen, and when there are few of them, the oxygen deliver isn't efficient.) This overworking of the heart can actually cause congestive heart failure, so this and other complications (weakness, lethargy) make darbe/Epo supplementation more of a necessity. For general reference, a chest x-ray is always a good idea if you have an anemic cat and need to do a transfusion; if the heart is very big, the cat is in more danger of CHF when given fluids and transfusion.

    I have probably asked you already, but does Bear have an internal medicine specialist, or do you have one available to you in your area? He or she might have more ideas. Stopping the blood loss is important, but if the kidneys are in such a state that they can't produce enough erythropoetin, using darbepoetin is very reasonable. It doesn't sound like the benefits of withdrawing benazepril are immediate so you may need to take action sooner rather than later. I'd discuss it with your vet tomorrow, and see if darbepoetin is available.

    Sorry you and Bear are going through this, Linda. Let me know if I can help further.

    PS. I asked about bone marrow: this is one of the diagnostic tests for anemia, to see if there is a bone marrow problem that is causing it. I didn't do one on Earl because anesthesia would be a problem for him, too, and also for certain reasons, the results wouldnt have mattered much in his case.
     
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