C10004726 / invoice 10000

Email from Animalius:
Dear Dr Criddle,
A further update re Nugget:
Update with Holter report by Assoc Prof Meyers:
'24hr Holter ECG Results (12/2/26 at 8:41am): 
On assessment of the full disclosure the following was noted: 
1. Sinus rhythm and sinus arrhythmia were sustained throughout the recording. Total QRS complexes = 120,450. Heart rate ranged from 21-213bpm (average 84bpm).  
2. Ventricular prematurity was identified frequently (n=4,722). Ventricular prematurity occurred as isolated VPCs (n=4,419),  couplets (n=96) and non-sustained runs (n=27) of up to 7 consecutive complexes. Ventricular prematurity was multiform, R-on-T complexes were 
identified with a maximal instantaneous rate of 290bpm. 
3. Supraventricular prematurity was identified as isolated prematurity (n=4,166). 
4. No pauses >4 seconds. 
Diagnosis:  Ventricular arrhythmias (Lown Grade V) 
Conclusions: 
While risk for syncope and sudden death can not be eliminated with dilated cardiomyopathy, this Holter ECG demonstrates the highest grade of ventricular arrhythmias despite flecainide therapy. Flecainide 75mg TID is maximally dosed, and further increases in this medication are not known to have additional efficacy. Sotalol 40mg BID may be an appropriate additional antiarrhythmic agent but 
echocardiographic reassessment  is indicated and must exclude moderate-severe systolic dysfunction for sotalol to be considered. If moderate-severe systolic dysfunction is present in this patient with preclinical DCM, sotalol should not be considered. Rather, discontinuation of flecainide and commencement of mexiletine 7-8mg/kg TID is advised.  
A repeat 24hr Holter ECG is advised following adjustment in antiarrhythmic therapy to confirm efficacy.'______________________________________
Assessment: recommend to commence mexiletine at 250mg TID and repeat Holter examination in 3 weeks.  Once mexiletine commences, flecainide to stop.  Mexiletine requires compounding.  Script to be provided to owner who can contact compounding chemists for costing.  Recommended compounding chemists: BOVA, Oxford Compounding, Maylands Compounding Pharmacy, Pharmacy 777 group.
Risks of medication: main issues are usually related to GI tolerability of the medication. Seizures are a very rare reported adverse event.
George has been updated by telephone and will reach out to Pharmacy 777 first.  A script is written for mexiletine 250mg capsules (200) at 1 capsule TID.

Kind regards,
Fleur
Dr Fleur James BSc BVMS (Hons) FANZCVS
Registered Specialist Small Animal Medicine