Dr. Fett more med Q's

[miachic]

Hi Dr. Fett. My husband and I have been talking about my HF doc appt and taking the meds, etc. I have some questions for you about them that I need to know that she doesn't take the time to explain.

1) If I don't take the meds at all, what is my prognosis? I am fully recovered and I'm just wondering if I don't start on the meds if it will have any adverse effects (by not taking them)?

2) Since I'm asymptomatic, fully recovered and feeling and doing great, are the meds more for "preventative" measures than anything else, i.e. to prevent me from going back into CHF and worsening my cardiomyopathy? Why exactly would they put me on something if I don't have symptoms, recovered, BP and HR are great, etc.? Just curious.

3) I am still trying to decide whether I should A. start taking them, B. if I do take them whether I should continue nursing, or C. start taking them and weaning. I'd like to make it to January with nursing my son. Would it be to my detriment to wait to take the meds? Obviously if I weren't recovering, were symptomatic, etc. I wouldn't consider NOT taking them and would go ahead and wean and just have them put me on a BB and ACE. However, I'd like to continue nursing and don't feel comfortable taking meds while nursing but am having a difficult time deciding what to do. I'm just curious as to if it matters whether I start them now or in a few months since my heart is back to normal?

4) From your point of view, if I start on an ACE and/or BB and I tolerate the lowest dose, do you think I would need to be titrated up? And why do they titrate up anyway? The docs said the other day that they would give me the lowest dose to start with "just to have it circulating in my body". (This is one of the reasons I am wondering whether it's being used for preventative measures.)

5) I just started taking CoQ-10 with permission from the HF doctor. This is the only thing I'm taking as of right now until I decide about the weaning/taking meds subject above. How can this help my heart and PPCM? I've read alot about it but I'm just curious what you would have to say about it.

6) Do you think that if I started on the meds it would give me a better chance at having a successful pregnancy again versus not taking them (would it help my heart out if I started on the meds NOW and took them up until I got pregnant and then stopped the ACE but continued the BB)?

Thanks again! I'm glad you're ever so patient with me ;).

[JAMESFETT]

Emily, I do think those are mostly questions to discuss with your prescribing doctor. Your doctor wants you to take medications, and therefore has good reasons for making that recommendation. I agree with your doctor. Co-Q10 may be helpful but there is no study to prove it has any effectiveness. I would have no qualms about giving a nursing mother carvedilol.

James

[miachic]

Thanks! Unfortunately, she won't really discuss anything with me and just throws things at me. She is always in a hurry to see me and seems like she never has time to go over anything with me. I think I'm going to try and get in to see my regular cardiologist and discuss these things with him. He has been more patient and taken more time with me in the past. Maybe I can get some more clear cut answers from him and he will actually take the time to make me feel like he is making my visit worth my time rather than just shoving meds down my throat without answering my questions. I guess it just frustrates me that she won't take the time to talk about my concerns in more detail. I just want to know all this stuff before taking the meds...just like I would want to know all my risks in the future about future pregnancy. Hrmph. We'll see where I go from now.

Thanks again!

[miachic]

Hi Dr. Fett. I know you've talked about carvedilol alot. I was recently reading about meds in the nursing mom. Is there a time when the secretion of this med would be the highest that I could avoid nursing and pump and dump if I need to? It suggested that if there is a timeframe ( i.e. one to two hours before or after medication dosing) that the concentration is the highest, that the nursing mother could possibly avoid nursing in that timeframe to avoid exposing the baby to the highest concentration of the med. Do you know if this is true for this med or not? I know the Captopril they want to put me on is a t.i.d. dosing so there isn't a timeframe that there would be less in my system. Since they would start me out on 3.25 mg of Coreg once a day, what's your take on the secretion in breast milk? Any opinions from you on this?

I'm just really concerned about the level of medication that's passed on to Isaac and am having a very difficult time deciding whether to wean or keep nursing and take the meds (for my own personal fears of meds being passed and the well being of my child).

Thanks again!

[JAMESFETT]

With any medication taken regularly long-term, your body reaches a "steady state" when the level remains pretty much the same, so the amount in breast milk at any one time would be approximately the same. The captopril would not be acceptable to expose a baby to, different category than beta-blockers. In addition, why captopril? It is the oldest of the ACE-inhibitors and has a definite disadvantage over newer ACE-I's in that it has to be taken 2 or 3 times per day (as opposed to newer once per day) to maintain levels, and therefore harder to remember each dose. We use captopril in Haiti because it is the least expensive of the ACE-I group; but if it were not for the cost, we would select another ACE-I where once daily dosing is OK. Nevertheless, lives are saved by the captopril, and PPCM women do return to normal function even in Haiti.

JD

[miachic]

Well, Dr. Fett, you just answered a ton of my unanswered questions w/o knowing you did so! Thanks.

They want to put me on Captopril because they said it's safe for nursing. I haven't read a whole lot that makes me thrilled to take an ACE-I while nursing. However, the BB seem to be a "safer" choice for nursing. They first chose Altace but since I wanted to continue to breastfeed, I had to call and tell them that it wasn't safe for nursing and they said "oh yeah, we forgot that you asked for something that was safe for nursing." So then they put me on the Captopril and said that I would have to take it three times a day because of how the medication works. So that was the decision from the last two visits. However, I've been doing research on the meds before I start taking them, again to see whether I should wean or not before starting them, and just haven't found enough about ACE-I with nursing that I am comfortable with. I think I will get to the point (probably sooner rather than later) that I will start taking a med just to see how I handle it and if it helps my heart improve that much more (and because of the research I've found so far on the meds with CHF). I just have to weigh the pros, cons, risks and benefits at this point not only to myself but also to Isaac. I know he would be fine on formula and takes a bottle really well, etc. He has actually been on formula off and on since birth because I had to supplement due to some breastfeeding problems in the beginning.That's one of my main reasons to want to continue nursing. We had so much trouble in the beginning that now that we are establised and he's a great nurser and we have a great nursing relationship, I hate to have to give that up so soon.

We'll see. I'm encouraged by what you've told me about Coreg so I've set my samples out to start taking probably this week or next. I will talk it over with my husband. That's the one that we've both felt safer with from the beginning.

Thanks once again. You're the greatest and I really appreciate your taking the time to answer my thousands of questions :o .