Steroids, anyone?!

RE: Steroids, anyone?!

Julian Earl — Fri, 19 Jun 2020 10:52:20 GMT

[ Steroids can be immunosuppressive but that is not a given if used at anti-inflammatory doses. Why do people continue to perpetuate this silly, illogical myth?! "Steroids cause immunosuppression" needs to be consigned to that ever growing dogma dustbin. ]

Sorry David, but I do not think that is illogical at all? What is inflammation? It is the first active line of a body's defence against disease is it not? Logically, reducing that response reduces the ability to fight off infections. I Why are they contra-indicated for Demodicosis for example? Because it permits the mite to thrive and multiply with a reduced response to the mite.

I accept that the extremely doses used in certain cases are likely to have a different degree of effect compared to "usual" anti-inflammatory doses especially if of short duration.

In other words I am still a little surprised that they are used. At lest there is peer-reviewed research now to back up their use whih is fine with me. I have not seen the dosage used nor the duration. but presumably those were included in the research. And, regardless of theoretical discussion about this is there any data on the incidence of relapses?

Thanks. Stay well and safe.

RE: Steroids, anyone?!

Anthony Todd — Thu, 18 Jun 2020 11:40:18 GMT

[quote userid="2122" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223599"] the Depo injection is only, ONLY, even given when the patient needs it [/quote]

Amen to all that, with the suggestion that oral pred [or your favoured C'roid] is quicker easier and cheaper than an injection.

I assume, too that, the "depo" jab will probably last longer than necessary, with most intermittent allergic insults so you lose the chance of matching the sudden itch with a visit to grandma's cat etc.

Just remember not to give 3 to 5 times the recommended dose to any animal [in jest and a nudge]

RE: Steroids, anyone?!

George Cooper — Wed, 17 Jun 2020 22:04:10 GMT

Interesting commentary from Danny Scott, via Beats. It was Danny Scott, I'm certain, who introduced me to the so-called Pulse Dose system of steroid treatment. He rolled up to his first BSAVA wearing most fetching Jesus Creepers, and a colourful bandana somewhere around his head or neck, and after the introduction took the 2-3 paces forward up to the podium and lectern, and fixed us all, every single one of us, with an unwavering stare, taking a good few minutes to do so, before raising his 2 fingers into that well -known "salute" and drawling "Well - Hi, y'all". Thereafter he steadfastly referred to "Zits" amongst the welter of science that he had investigated and found answers for. I swear he made many lifetime friends that day.

The Pulse Dose essentially is the system that gives the dog peace from constant scratching which of course is exactly what owners are after, and the key to the success of it is that the Depo injection is only, ONLY, even given when the patient needs it - as opposed to the lifetime of prednisoone which confers the most distressing of side effects withput fail. Having used the system for 25-30 years , and carried sceptical colleagues with me, I am persuaded that it is both cost effective and humane, and required constant veterinary supervision - something that other systems perhaps get away without.

RE: Steroids, anyone?!

Anthony Todd — Wed, 17 Jun 2020 09:31:50 GMT

[quote userid="12930" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223542"]steroid group more PUPD[/quote]

One thing that should again be emphasised, and corrected, is the use of Csteroids daily when, say pred, has about a 5 day effect.

This means for 5 days the patient is on an increasing, and therefore unnecessary overdose, which must be more likely to cause the legendary catastrophic side-effects.

Before anyone jumps in, this doesn't apply to the long-acting preps where the single dose has declining blood levels, theoretically from soon after the time of dosage.

This has another advantage in that intermittent dosage allows any anti-allergic trial [eg flea treatment] to show, thus the elimination of unnecessary repeat dosage.

But this SOF [retired] has said this often before.............

RE: Steroids, anyone?!

Beats — Tue, 16 Jun 2020 20:25:38 GMT

[quote userid="11308" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223536"]There are a lot of studies for the newer allergic skin disease drugs (atopica, apoquel, cytopoint etc) as well as immunomodulatory drugs for immune mediated diseases that compare the new drug with prednisone as it is the base to compare new drugs to - they show differences in efficacy, issues with side effects etc.[/quote]

But the differences in efficacy often favour the steroids?

And the issues with side effects are hardly clear-cut. Classic paper comparing methylpred to ciclosporin for atopy:

https://pubmed.ncbi.nlm.nih.gov/12603681/

steroid group more effective

ciclosporin group more GI upsets

steroid group more PUPD

Whats's missing is 10 year survival and relative risk of neoplasia with the 2 drugs.

To claim ciclosporin is safer than steroids (or even associated with less side effects) is both premature and (in my opinion) unlikely.

[quote userid="11308" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223536"]If these new drugs weren't better than steroids for whatever reason that may be we wouldn't be using them so much[/quote]

Not everyone does use them so much either. If what you are doing is already working...

I quote from a now retired vet passing comment in 2015 (OK, so he couldn't have been using cytopoint or apoquel then I think, but that just shows how little we know about their long-term use):

"That dog is initially going to get immunosuppressive doses of corticosteroid [re question regarding approach to symmetrical lupus onychodystrophy]. That’s the only thing for me that turns that dog around. Then after the dog’s feeling well, I’ve got the acute disaster under control, then the question is when do I stop the steroid. Note I didn’t say taper – I haven’t tapered steroids for 35 years…."

“And you don’t use ciclosporin in them?”

“I don’t use ciclosporin hardly ever for anything.”

“Why?”

"[Chuckle] Whether it’s atopy, whether it’s autoimmune disease, number one ciclosporin is the most expensive drug in my pharmacy… And clinically… I can remember very few cases where I had to resort to ciclosporin because all my other options did not work... You’re talking to a palaeodermatologist.. I’m quite happy with where I am and where my patients are."

Some of those comments may seem familiar and comparable to mutterings of another retired vet, but they happen to be Danny Scott's.

BSAVA Congress 2015 [end of talk on nicotinamide / tetracycline, the audio of which is filed incorrectly under cat atopy if you are looking for it in the archives].

RE: Steroids, anyone?!

David Mills — Tue, 16 Jun 2020 19:35:06 GMT

[quote userid="3094" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223538"]I am still surprised at a serious viral disease being the subject of steroid use. Basic principles isn't it? [/quote]

Oh jeez, veterinary dogma no 1. By some way.

Steorids can be immunosuppressive but that is not a given if used at anti-inflammatory doses. Why do people continue to perpetuate this silly, illogical myth?! "Steroids cause immunosuppression" needs to be consigned to that ever growing dogam dustbin.

RE: Steroids, anyone?!

Julian Earl — Tue, 16 Jun 2020 18:44:23 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223532"]till surprised at the prejudice entrenched deep in the dogma. Hopefully someone without these prejudices will do a proper trial so we can all follow the evidence![/quote]

Sorry Anthony, were you referring to me? I think that the adverse effects of steroids are well-established? What I have not heard, yet, is the likely duration of treatment My late mother developed terrible osteoporosis due to the chronic use of steroids for respiratory disease. Not nice for her , and mot particularly good for the NHS either! I am still surprised at a serious viral disease being the subject of steroid use. Basic principles isn't it? First do no harm!?

Also I am surprised because the risk of side-effects following steroids seems to be much greater than for our patients? = More surprise at their use here...

RE: Steroids, anyone?!

Anthony Dennison — Tue, 16 Jun 2020 18:16:52 GMT

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223532"]Still surprised at the prejudice entrenched deep in the dogma. [/quote]

There isn't that much prejudice Tony. We all use steroids quite regularly, but not for as many conditions as there used to be due to more advanced drugs bring developed.

They are still the mainstay for immune mediated diseases (with additional meds alongside) and they are still given for skin cases quite regularly too for short term issues. I probably dispense steroids daily on average.

The development of veterinary medicine means we have more options available to us with fewer side effects when given long term (note - I'm not saying the side effects are an issue short term as you always say 'a short course of appropriate dose of steroids is all that's required' but unfortunately that's not always the case). When you first qualified treatment options were limited so steroids were a great tool as they had do many uses.

There are some people who are hesitant to use them in some cases but I wouldn't say people refuse to use them.

[quote userid="5904" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223532"]Hopefully someone without these prejudices will do a proper trial so we can all follow the evidence![/quote]

There are a lot of studies for the newer allergic skin disease drugs (atopica, apoquel, cytopoint etc) as well as immunomodulatory drugs for immune mediated diseases that compare the new drug with prednisone as it is the base to compare new drugs to - they show differences in efficacy, issues with side effects etc. If these new drugs weren't better than steroids for whatever reason that may be we wouldn't be using them so much

RE: Steroids, anyone?!

Anthony Todd — Tue, 16 Jun 2020 16:33:26 GMT

No but thanks for asking!

Yet still!! [sorry Arlo, but really.....!¬]

RE: Steroids, anyone?!

Bob Russell — Tue, 16 Jun 2020 16:23:45 GMT

If you watch the BBC item you will see they have done proper trials and the results are impressive. That is why they have released the information so early. The trials seem to have produced some exciting evidence and the suggestion is that as many as 5000 lives might have been saved if this treatment was given.

Clearly the human medics are not so gung ho with steroids as we might be when there is little to lose!

RE: Steroids, anyone?!

Anthony Todd — Tue, 16 Jun 2020 15:07:16 GMT

[quote userid="3094" url="~/001/nonclinical/f/life-in-practice-discussions/29160/steroids-anyone/223529"] Steroids? No but thanks for asking![/quote]

Still surprised at the prejudice entrenched deep in the dogma. Hopefully someone without these prejudices will do a proper trial so we can all follow the evidence!

RE: Steroids, anyone?!

Bob Russell — Tue, 16 Jun 2020 14:27:13 GMT

Corticosteroids are a logical treatment for a cytokine storm which is what causes the organ damage that is the killer. I doubt any will relapse or regress as a result but quite a few people may go home rather than being carried out in a box.

I wonder if dex will be part of the treatment (or is) for life-threatening influenza in the future.

RE: Steroids, anyone?!

Julian Earl — Tue, 16 Jun 2020 13:24:18 GMT

Prednisolone is very effective at improving cats with FIP, simply due to the potent anti-inflammatory effect but ultimately the prognosis is always poor. I would be interested to hear the medical justification for dexamethasone for COVID-19. ow many relapse or regress as a result?

Soin answer to the original question... Steroids? No but thanks for asking!