gingivitis/stomatitis

Re: gingivitis/stomatitis

Anthony Todd — Wed, 03 Jul 2013 19:22:02 GMT

Sorry, I was groaning because I had called it pain when I should have called it "suffering".

Re: gingivitis/stomatitis

James Laidlaw — Wed, 03 Jul 2013 18:22:09 GMT

[quote user="Anthony Todd"]What's the best pain relief [not including steroids]?[/quote]

Might I refer you to your own words before you groan that someone doesn't implicitly agree with all you say...

Re: gingivitis/stomatitis

Evelyn Barbour-Hill — Wed, 03 Jul 2013 18:13:23 GMT

[quote user="Anthony Todd"]I wonder if anyone has just done the clearance without all the add-ons; it may be that that is enough.[/quote]

Sure, sometimes.

Unless you count the few days' NSAID post-op as an add-on.

Re: gingivitis/stomatitis

Anthony Todd — Wed, 03 Jul 2013 18:00:49 GMT

[quote user="James Laidlaw"]steroids are a good analgesic.[/quote]

[groan] I've never thought or heard that steroids have any analgesic properties at all, but this is semantics, surely.

All I know is that, do your full clearance before during or after depomed and the cat is fine after a couple of weeks, or nearly so. And never relapses [unless you leave a root or two...]

The relief of discomfit is almost immediate ans the cat is eating and happy. I really don't mind if it hasn't had any analgesics at all.

I wonder if anyone has just done the clearance without all the add-ons; it may be that that is enough.

Re: gingivitis/stomatitis

James Laidlaw — Wed, 03 Jul 2013 17:39:42 GMT

One question - how much PAIN RELIEF do steroids provide? Once they abate the symptoms, sure, the animal is more comfortable, but I was never under the impression that steroids are a good analgesic. Obviously in conjunction you'd likely require an opioid as can't use NSAID at same time, and that can get all cascade-y and awkward.

Also, I noted you earlier said nothing "fixes" these as quick as depomed. Surely the bugbear with steroids is they treat SYMPTOMS very well, but often not the cause or a cure, hence long term use is usually the end result.

Again, nothing against appropriate use of steroids, but they are a bit like sweeping the problem under the carpet, rather than fixing it. I'm more than happy to be proved wrong on any of these points, they're just the way I've always understood things.

Re: gingivitis/stomatitis

Anthony Todd — Wed, 03 Jul 2013 14:06:02 GMT

[quote user="Martin Atkinson"]We do agree on something[/quote]

Has anyone had permanent remission without full dental clearance?

Does anyone think antibiotics of any variety make a significant difference on their own?

Does anyone think Pred, even at high doses works as well as Dmed? [if steroids are used, not that they must be]

What's the best pain relief [not including steroids]?

Do many get remission with diet change [often given as incidental advice]?

Then we can agree on more.....

Re: gingivitis/stomatitis

Martin Atkinson — Wed, 03 Jul 2013 10:55:28 GMT

[quote user="Anthony Todd"]I think we can agree that removal of all the molars and premolars is a given, or have you managed to get remission without that?[/quote] We do agree on something, my Holy Grail was to avoid this with interferon but like many before me I failed to find it. All of us that is apart from that person who posted up on here with some weird snake oil remedy she invented and Arlo told me off for giving her a hard time. Come to think of it where's the fruit basket antipodean RMB evangelist?, I'm surprised he hasn't hijacked this thread yet! We'll agree to disagree on the rest.

Re: gingivitis/stomatitis

Wren — Wed, 03 Jul 2013 10:03:02 GMT

[quote user="Rob Davis"]

There was a large variation in the individual absorption of oral cyclosporine (trough blood levels varied from 32.1ng/ml to 1576.2ng/ml!). Cats with a blood level over 300ng/ml appeared to do much better. Should we be routinely measuring blood cyclosporine levels as we do for phenobarbitone and digoxin?

[/quote]

I was on oral Cyclosporin for about 8 years for some sort of weird choroiditis/retinitis. The NHS regularly monitored my blood cyclosporin levels (think it got down to every 6 months once I was fairly settled). They also had me in hospital for a week having kidney function tests before starting me on the drug which was their standard protocol for anyone on cyclosporin. A week in hospital is a long time when you're 14 and not ill!

Re: gingivitis/stomatitis

Anthony Todd — Tue, 02 Jul 2013 20:35:27 GMT

[quote user="Thomas Johnson"]Here's an example for you,[/quote]

Of course that's worthy of note but I wonder what drugs all the other diabetic cats are on which never get associated with DM.

I shudder to think how many cats got repeated Dmed in the days before easy effective flea control [remember owner and cat resistance to Nuvan Top].

I should have seen many many DM cats 'cos we used a lot of Dmed mainly for FAD!! And if I missed them my colleagues would have found them and loved telling me too...

Re: gingivitis/stomatitis

Anthony Todd — Tue, 02 Jul 2013 20:27:24 GMT

[quote user="Martin Atkinson"]Depomed may be the only product that it is practical to give to a cat with intractable pain that is impossible to pill or give tablets crushed in the food, when every other option has failed and the owners have been warned of the possible side effects including DM and/or they cannot afford/not prepared to pay for other options and is the most humane thing to do for the cat other than euthanasia but is the treatment of last resort.[/quote]

No Depomed is the only product to give to a cat with intractable pain that is impossible to pill or give tablets in food and even if you could .

Period.

And IMHE they all got better but after the dental clearance .

I'd be happy to treat with all the other things but only after the immediate and total relief of pain following the dental clearance and Dmed, in fact, come to think of it, I used to give Dmed and do the dental a week or so later.

Try it, you will be surprised.

Re: gingivitis/stomatitis

Anthony Todd — Tue, 02 Jul 2013 20:19:30 GMT

[quote user="Martin Atkinson"] As I've said I've NEVER had to resort to Depomed for one of these they have all been resolved with combinations of dental hygiene, antibiotics, NSAIDs and interferon.[/quote]

It looks like I'll have to stand for a while, like to know the time scale for pain relief though.

I think we can agree that removal of all the molars and premolars is a given, or have you managed to get remission without that?

And I do query whether depomed has any long term side effect when offset against the immediate total relief it gives to the cat.

And the number of cats that become diabetic without ever having depomed?

It could be that depomed has a preventative action [ducks behind the sofa] but you must admit I've got a point.

[quote user="Martin Atkinson"]To do otherwise is IMO unprofessional.[/quote]

Oh dear, then I've been unprofessional for some years with, after dental clearance and the dreaded dmed ,many cats being happy and pain free with as far as I recall no DM and no relapse.

Re: gingivitis/stomatitis

Martin Atkinson — Tue, 02 Jul 2013 19:14:54 GMT

[quote user="Anthony Todd"]I think everyone here would reckon depomed is better than pred for this condition.[/quote] Clearly not Anthony you really are still burying your head in the sand. Depomed may be the only product that it is practical to give to a cat with intractable pain that is impossible to pill or give tablets crushed in the food, when every other option has failed and the owners have been warned of the possible side effects including DM and/or they cannot afford/not prepared to pay for other options and is the most humane thing to do for the cat other than euthanasia but is the treatment of last resort. To do otherwise is IMO unprofessional. As I've said I've NEVER had to resort to Depomed for one of these they have all been resolved with combinations of dental hygiene, antibiotics, NSAIDs and interferon.

Re: gingivitis/stomatitis

Thomas Johnson — Tue, 02 Jul 2013 19:04:40 GMT

[quote user="Anthony Todd"]

Still waiting for Sarah's dose rates and durations so that I can sit down after her "2 cases in the past year" of Depomed induced diabetes.

[/quote]

Here's an example for you, 11 year old female neutered DSH weighing 4.5kg, presented to me on 1 November last year, pruritic, skin very inflamed and fleas seen. Given an injection of 0.3ml DepoMedrone, topical flea treatment and household spray. Presented to me again on 10 December having been pu/pd for the past month, now lethargic, vomiting and inappetant. Elevated blood glucose and fructosamine, ++++ glucose in urine. Started on Caninsulin, responded very well, stable until April when she went into remission.

Re: gingivitis/stomatitis

Anthony Todd — Tue, 02 Jul 2013 15:15:39 GMT

Dug around and found this:

http://jfm.sagepub.com/content/13/8/577.long

This is where the article in Vet Times got the dose of pred from [or vice versa] but not only is the dose low and tapered after 7 days, but I think everyone here would reckon depomed is better than pred for this condition.

This is the sort of unscrutinised "evidence" that discredits steroids and , IMHO, unjustly, as a treatment for this painful condition.

Re: gingivitis/stomatitis

Anthony Todd — Tue, 02 Jul 2013 14:51:58 GMT

Still waiting for Sarah's dose rates and durations so that I can sit down after her "2 cases in the past year" of Depomed induced diabetes.

I suppose it would be sensible to ask how many cats developed diabetes in the past year that hadn't had depomedrone??

Re: gingivitis/stomatitis

Martin Atkinson — Tue, 02 Jul 2013 10:34:00 GMT

[quote user="Anthony Todd"]

[quote user="Sarah Keir"]I've seen 2 cases in the past year that developed diabetes after depomedrone injections - but one was a Burmese so perhaps it was going to happen any way.[/quote]

I stand corrected. What dose rates and at what intervals? [ Then I might sit down again....]

[/quote] Anthony et al of the dynasty of steroid kings, I've been telling you this for years. Nobody is steroidophobe there just those of use who use them appropriately not as blanket therapy without trying safer alternatives first. For sure there are cases when corticosteroids are the best/only choice but if you haven't seen undesirable and as Sarah highlights potentially life threatening side effects you are in cloud cuckoo land or very unobservant. For no other reason than the fact that no-one really knows the true pharmacodynamics of the damned stuff you should not use it until you have explored other alternatives. You yourself have effectively admitted that you are virtually unaware of the benefits of interferon so you haven't reasonably considered alternatives. Getting pissed every night is guaranteed to make me happy but that doesn't mean its the best way and it will not be without long term repercussions.

Re: gingivitis/stomatitis

Anthony Todd — Mon, 01 Jul 2013 20:25:15 GMT

[quote user="James Laidlaw"]No-one has come out as a steroidaphobe - not sure where this is getting you so worked up? [/quote]

I do bang on, I know, but it's so frustrating when I see cases where the cat [and dog,with lick granulomas] that have been fiddled about with for weeks and at some expense and not improving because steroids have either not been used at all [antihistames were favoured out of one university] or used at hopelessly inadequate doses but long periods. [see my quotes before]

Go through this thread and almost all the references to steroids are negative in some way but positive when there is talk of other approaches even if all the other treatments give a delayed relief from suffering if any relief at all.

Still I suppose I should shut up 'cos these other treatments ain't cheap and they don't fix 'em quickly.

[quote user="James Laidlaw"]I will agree that they do seem to have a bad rep, possibly was drilled into us at university (it was in NZ).[/quote]

Yes, but why, that's what nobody seems to explain

Re: gingivitis/stomatitis

Anthony Todd — Mon, 01 Jul 2013 20:12:28 GMT

[quote user="Sarah Keir"]I've seen 2 cases in the past year that developed diabetes after depomedrone injections - but one was a Burmese so perhaps it was going to happen any way.[/quote]

I stand corrected. What dose rates and at what intervals? [ Then I might sit down again....]

Re: gingivitis/stomatitis

Sarah Keir — Mon, 01 Jul 2013 17:48:38 GMT

[quote user="Anthony Todd"]

I don't think I've ever seen diabetes etc with depomed

[/quote]

I've seen 2 cases in the past year that developed diabetes after depomedrone injections - but one was a Burmese so perhaps it was going to happen any way.

I am currently managing a difficult case of FCGS in a vicious cat. I was unable to examine it except after triple in a crush cage and the owners can only medicate by putting stuff in food. We tried diets and metacam and convenia injections then resorted to steroids and the usually angry cat now needs its mouth prised open for me to see inside rather than being hissed at. I have now extracted all teeth so hopefully can reduce steroid dependency but the steroids gave this cat its quality of life back.

Re: gingivitis/stomatitis

James Laidlaw — Mon, 01 Jul 2013 17:40:05 GMT

No-one has come out as a steroidaphobe - not sure where this is getting you so worked up? I think people are just saying you need to be prudent with their use and not use them when they may effect future treatments. This may be appropriate or inappropriate and decided on a case by case basis depending on client wishes, costs, extent of problem etc. There's no one hard and fast rule to always use or always not use steroids.

I will agree that they do seem to have a bad rep, possibly was drilled into us at university (it was in NZ).

Re: gingivitis/stomatitis

Anthony Todd — Mon, 01 Jul 2013 15:06:15 GMT

"This means using a short-acting molecule (prednisolone) at the lowest effective dose rate such as 5mg twice

weekly or 2mg every other day tapering downwards"

Again, an ineffective drug used, as usual, at an ineffective dose rate, so no wonder it didn't work well!

I don't think I've ever seen diabetes etc with depomed but I certainly have with megestrol but, there again, only when used in high doses and continuously, [like 5mg daily for 2 years!!!] never a problem if used when necessary and in intermittent minimal but effective doses.

As usual the steroidophobes omit mentioning this and always cite the continuously overdosed.

Re: gingivitis/stomatitis

Anthony Todd — Mon, 01 Jul 2013 14:52:46 GMT

[quote user="Alex Allen"]Comparative study of recombinant feline interferon omega and prednisolone published in JFMS, 2011. Free access article[/quote]

Yes, but typically as I said earlier the pred was at 1mg/Kg for 7 days only then halved progressively.....

Test it against depo and see; Pred in these cases never worked at all for me.

Re: gingivitis/stomatitis

Martin Atkinson — Mon, 01 Jul 2013 10:28:16 GMT

[quote user="Anthony Todd"]How long does it take for the interferon to take effect and would there be any disadvantages to give some dreaded steroid to get quicker relief ?[/quote] The problem with answering the first part of this question directly is that I've never used interferon (Virbagen Omega) as a single entity in these case because they are multi-factorial and require a multi-modal approach and it would be un-professional in practice to just give interferon when a cat had severe dental disease without dealing with the dental problem. So my approach in a severe case of gingivo-stomatitis would be to perform the dental treatment and give intra-lesional injections of Virbagen Omega at the same time and would follow up with antibiotics, NSAIDs and oral Virbagen Omega. Sadly this is where the anecdote takes over as in practice I don't have the numbers of cases to be statistical but IME the improvement in cats in which I've used this treatment has been clinically better than those where I haven't and at one week post treatment this improvement was markedly better that I would have expected without interferon. However, as said before it is not the holy grail I was looking for and It is difficult to justify the expense of this treatment for the results obtained so I confess I use it very little these days but I've not had to resort to cortico-steroids in any of these cases.

This was written up in precis by me in Evelyn's own esteemed dental society journal in 2010 and Veterinary Times in depth before that but I don't have access to the exact references at the moment.

Re: gingivitis/stomatitis

Alex Allen — Mon, 01 Jul 2013 09:32:56 GMT

Apologies if these links have already been posted but I quickly scanned the previous posts and couldn't see them.

Comparative study of recombinant feline interferon omega and prednisolone published in JFMS, 2011. Free access article

http://jfm.sagepub.com/content/13/8/577.full.pdf+html

And a very good article in Vet Practice, July 2012 by Norman Johnson reviewing the latest knowledge on this syndrome - accessible on this website -

http://www.vetsurgeon.org/blogs/veterinary_practice/archive/2012/06/21/july-2012-edition.aspx

Re: gingivitis/stomatitis

Rob Davis — Sat, 29 Jun 2013 14:06:14 GMT

[quote user="Anthony Todd"]How long does it take for the interferon to take effect and would there be any disadvantages to give some dreaded steroid to get quicker relief ?[/quote]

From Margherita Gracis's notes when discussing her trial: "Adjunctive treatments may be necessary to acompany virbagen omega treatment especially during the first 15 days" (adjunctive treatments used in this study were clindamycin and meloxicam).

BUT: [quote user="Rob Davis"]There appeared to be a reduced response to cyclosporine in cats which had previously been treated with steroids (sic), though the numbers were to small for statistical significance.[/quote]

This was from the cyclosporine study, but it is possible that pre-treating with glucocorticoids may reduce the efficacy of other subsequent treatments. Personally I would avoid them if possible, but sometimes they may be necessary.