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Prior to therapy, the heartworm patient is assessed and rated for risk into one of four categories. The microfilariae which are the newborn children of the adult worms living in the heart and pulmonary arteries. Happily the microfilariae, L3, and L4 larvae can all be killed by monthly ivermectin based heartworm preventive products (i.e. The only product currently available for the treatment of adult heartworms is melarsomine dihydrochloride (immiticide® made by Merial). The patient receives an intramuscular injection deeply in the epaxial (lower back) muscles as shown at right. In the 2 dose protocol, the dog comes back for a second injection the next day on the opposite side of the lower back. After treatment, the patient must be strictly confined for one month following the final treatment. Melarsomine treatment is expensive and often out of reach for rescue groups, shelters, and many individuals. This means that if one opts to treat a heartworm positive dog with an ivermectin heartworm preventive only, one can expect the dog to remain heartworm positive for as long as 2 years and the heartworm disease will be progressing during that 2 years.
There is another aspect to this treatment which is important to mention and that is the development of resistant heartworm strains. Heb je altijd al jouw verstand van quizen willen testen nou hier doe je dat er komen vragen over verschillende youtubers die jij denkt te kennen.
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Important factors include: how many worms are thought to be present based upon the tests performed, the size of the dog, the age of the dog, concurrent health factors, severity of the heart disease, and the degree to which exercise can be restricted in the recovery period. These dogs are typically without symptoms and their infection is a surprise discovery during a routine annual health examination when a positive test comes up. Healthy dogs with minimal signs as above, occasional coughing, fatigue only with exercise but with radiographs that show definite evidence of heart disease. Dog is suffering from weight loss, cough, difficulty breathing, blatant damage to the vasculature is apparent on radiographs, lab work reveals a more severe anemia and marked urinary protein loss.

The microfilariae are swimming freely in the bloodstream possibly in large numbers and it is the microfilariae which can (through a mosquito) spread to other dogs. This group requires the arsenic compounds for destruction while the other two groups can be killed with less toxic products.
To achieve this, treatment is approaches in stages with the goal being to minimize the number of adult worms to be killed and having the patient as healthy as possible going into what is called "adulticide" treatment. If one goes by the manufacturer's recommendations, treatment can be done in 2 doses or 3 doses depending on the Class of heartworm infection. This is a painful injection with a painful substance and it is common for the patient to be very sore at home afterwards. In the 3 dose protocol, the dog comes back one month later for 2 doses 24 hours apart (the first dose representing an introductory treatment to kill some of the more sensitive worms.) Keep in mind, too many worms dying at once creates circulatory shock. The most critical time is 7-10 days following a melarsomine treatment but they can occur anytime in the following month. If the dog is stable (Class I) one option is to simply leave the dog on an ivermectin based preventive. Using heartworm preventives long term in dogs with adult heartworms, leads to the production of heartworm preventive resistant microfiliaria. The important concept to realize is that very harsh arsenic based drugs are necessary to kill adult heartworms and that treating for heartworm infection is neither simple nor safe in itself. Lab testing shows mild anemia, urine dipsticks show some protein present but not severe urinary protein loss.
The damage to the lung blood vessels from the worms, creates extra resistance for the heart to pump against and often episodes of collapse occur with exercise. Heartworms visible by ultrasound in the AV valve of the right side of the heart, very abnormal bloodwork.
These will continue their maturation and repopulate the heart and pulmonary arteries if they are not killed before the adult worms. Some dogs will need anti-inflammatory doses of steroids to control the inflammation that stems from the presence of worms. Most universities, however, opt to treat all patients with the 3 dose protocol as it creates a more gradual kill of the adult worms (which is safer in terms of embolism and shock). The benefit of the 3 dose protocol (sometimes called the "split dose" protocol) is that the first injection serves to kill off any older or weaker worms without killing off the stronger, younger ones.
This option has led to a great deal of misconception about the ability of ivermectin to kill adult heartworms. In other words, this "slow kill" method of treating heartworm infection leads to strains of heartworm that cannot be stopped by any of the heartworm preventives presently available on the market.
Wolbachia organisms seem to be protective or beneficial to the heartworms that harbor them and it has been found that killing the Wolbachia with an antibiotic such as doxycycline is very helpful in the treatment of the heartworm infection.
If the damage is severe enough, the heart can actually fail trying to pump through all the clogged up blood vessels.
These dogs are dying and can only be saved by the physical removal of adult heartworms via an incision through the jugular vein.

Since our goal is to have fewer adult worms when the time comes to kill the adult worms, it behooves us to kill the younger worms right off the bat.
The newer products such as the selamectin and moxidectin products do not clear microfilaria well enough to be used in the treatment of an active infection so right now the ivermectin based products seem to be the best for this use. When the two consecutive doses occur one month later, there will be fewer worms dying at once.
The reason for this is that embolism to some degree is inevitable and it is important to minimize embolism-related problems. Heartworm preventive resistance has now been documented in some of the heartworm strains of the Mississippi river delta area and inappropriate use of heartworm preventives is felt to be the cause. Without their Wolbachia, many female heartworms are unable to reproduce and L3 larval heartworms are not able to infect new hosts. This price is subject to change due to finance deal, cash deal, zip code, or amount of available rebates. Class III dogs are expected to die without treatment but are, unfortunately, sick enough that treatment itself is not without risk. If such a dog can be saved from this crisis, further heartworm infection treatment cannot be contemplated until the dog is stable enough to fit into one of the other categories above. The American Heartworm Society recommends 1-3 months of a preventive prior to treating the adult worms. Exercise increases heart rate and oxygen demand and we need the heart to rest during this recovery period. Previously, the "slow kill" method of heartworm treatment was deemed acceptable for dogs in the Class I (early) stage of heart disease but this has changed given confirmation of resistant strains. The use of antibiotics in this way, along with the use of a heartworm preventive, forms the basis for what is called the "slow kill" method of treatment, as described above. How long one chooses to wait depends on how urgent the dog’s need is to remove the adult worms.
Approximately 30% of dogs experience some sort of injection site reaction which resolves in 1-4 weeks. The Companion Animal Parasite Council now recommends that the "slow kill" protocol using heartworm preventives NEVER be used regardless of whether the patient is in Class I stage of infection or not. After all, it is the adult worms that cause heartworm disease, not the immature worms addressed by the preventives. Heartworm infection should be dealt with definitively and promptly so as to preserve the effectiveness of the medications we have.
It is more appropriate to use doxycycline to "pre-treat" the dog prior to adulticide therapy as a way to reduce the number of worms to kill and reduce reactions when the arsenic based product is ultimately used. The use of doxycycline in this way has become quite common in heartworm treatment protocols.

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