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Dr. John
Dr. John, Texas Veterinarian
Category: Cat
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Experience:  Over 14 years of clinical veterinary experience
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Hello, I have a 5 year old strictly indoor female cat who

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I have a 5 year old strictly indoor female cat who has a heart murmur. My original vet called it level 3 murmur and indicated she may not have a long life span, since the murmu was obvious before she was a full year old. My current vet called it level 2, and was surprised to see that my cat was prescribed enalapril, and thought we should explore other options, but wanted to run many expensive tests and imaging and I couldn't afford it all, so we stuck with the enalapril. She has been on enalapril for about 4 years. She takes half of a 2.5mg tablet once daily. The original vet who prescribed it said it would not cure the heart murmur, but it would make it 'easier' for her heart to work and hopefully prolong her life. Her blood pressure was monitored regularly during the first couple years, and everything was fine. She's been vomitting a few times a month for the past 6 months or so, and started having frequent diarrhea a few weeks ago. I took her to the vet, and the vet tested her for parasites and infection, and nothing was positive, so the vet said it was just 'stress' because we were in the middle of packing and moving. The vet gave me probiotics and some herbal mixture to settle her stomache, and it stopped the diarrhea for a few days. We have been in our new place for about a month now and the cat seems happy and well-adjusted to her new home. But, her vomitting and diarrhea have started up again. The diarrhea has a LOT of mucus and sometimes a bit of what looks like a blood spot in it.
Since she vomits so frequently, my question is can or should I stop the enalapril? I think vomitting and diarrhea are side effects of the medication. Since my vet can find no obvious cause for the vomitting and diarrhea, should I assume it is the medication? Over the 5 years I have had her, she has had somewhat frequent respiratory infections, though they became MUCH less frequent after she started the enalapril. She has also been a regular vomitor about once a month since I've had her, but I thought that wasn't too extreme for a cat. I have skipped her pill occasionally for a day or two, either by accident or due to traveling. She seems 'happier' when she doesn't take the enalapril, and more bright-eyed and active. I don't want to keep giving her a medication that is making her sick, but I don't want to stop a medication that may be prolonging her life. What can I do?
Hello. Thanks for writing in. If she has been on the medication for 4 years and has been on the same dose, it is unlikely that it would be causing the gastrointestinal upset. Usually those side effects are seen sooner after starting the medication and tend to be self limiting. I would suspect that there is a separate medical issue going on. With the blood and mucus in the stool, it is usually coming from inflammation in the colon (colitis). While parasites are a common cause, we will tend to see it a lot in cats with inflammatory bowel disease/irritable bowel syndrome (IBD/IBS). A food allergy, dietary sensitivity, dietary indiscretion, liver problems, pancreatic problems and masses in the colon other possible causes. Being that bloodwork was normal, I would lean more towards a dietary or IBD/IBS problem. You typically do not see changes on bloodwork with these issues. A dietary food trial or colonoscopy and biopsy of the colon are usually necessary. I would start by putting her on a higher fiber diet. Your vet can recommend a prescription high fiber diet. That is usually the best way to go. Adding 1/2 teaspoon of Metamucil or pure canned pumpkin (not pie filling) to each meal can help as well. I would get her on a course of Metronidazole to decrease intestinal inflammation and regulate bacterial overgrowth. I would see if your vet has Fortiflora to use as a probiotic. In some cases, they need to be put on a steroid for IBD/IBS issues. Your vet may or may not want to do that without a confirmation from biopsy, but I have before if bloodwork is normal. It is just not ideal with her underlying heart issues. If a higher fiber diet is not helping as much, you may need to get her on a prescription hypoallergenic diet. Please let me know if you have any other questions. Hope this helps.
Customer: replied 4 years ago.

Thank you for the reply. I will treat the gastrointestinal issues with probiotics, fiber and diagel. That sounds good. She's been eating the same food (Iams) for years too, so there was no change there to trigger anything. Hopefully it is the stress of the move.


I still have the general question though regarding the enalapril. Since I've had two vets have two strongly opposite oppinions regarding the use of enalapril for heart murmur in a cat, I would like a third opinion. She's been on it for years, and she vomits somewhat regularly (not including this current gastrointestinal episode), about once a month and her bowel movements smell worse than any BM I have ever encountered from a cat (even when it's not diarrhea). In your opinion, in a cat with a murmur level 2-3, do you think the enalapril is helpful? She seems so much happier and more active when I skip a dose or two. I don't mind continuing the medication, I'm just not sure if it actually helps or not. What do you think? Thanks!

You are welcome. Even with being on the same diet for years, they can still develop a sensitivity or allergy to an ingredient. Allergies often develop from constant exposure. The problem with treating heart problems is that you cannot determine that just from the murmur. Some cats with significant heart issues may not even have a murmur. Some cats with higher murmurs may not even have any significant changes in heart size and thickness. In order to really determine the best course of medication is to get an x-ray and ultrasound of the heart. That is the only way you can truly answer those questions. Starting medications without significant changes in heart size or thickness is a controversial subject. Some vets say start on meds before changes start because once changes start, it is more difficult to control. Some would say to wait until there is evidence of changes in the heart. There is not really a straight forward answer to the question. I typically try to avoid giving any medications until x-rays and ultrasound have been evaluated. I can't really tell you to stop the medication, though. Only your vets can legally do that. I would voice your concerns, though. Hope this answers your questions. Let me know if it doesn't.
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