Dexamethasone

steroid side effects

NSAIDs

Prednisone

NSAID side effects

crate rest

Medrol (MPP)

stomach protectors

wash out time

NSAID Side effects/overdosing 

NSAID Side Effects

Gastro-Intestinal

• Loss of appetite (nausea)- pain in stomach from ulcer, signs of drug toxity

• Foaming at the mouth due to seizures or bile coming up from an irritated and damaged stomach lining

• Flecks of blood in the vomit- There is fresh red blood from the bleeding stomach lining.

• Vomiting- upset stomach, often an indicator of an ulcer

• Stools that are black, tarry or bloody (red) in appearance—black/tarry is digested blood from high in the GI tract (stomach or small intestine), red is from lower in the GI tract

• Drinking more water- a late sign of severe bleeding/dehydration from an ulcer; also a sign of kidney failure. The kidneys become unable to filter properly and so there is increased urination causing increased water intake.

• Increased urination—a sign that the kidneys are being overworked to process the drug.

• Change in color or odor of urine – a sign that the kidneys are being overworked to process the drug

• Reduced blood flow to the kidneys causing decreased urine production and kidney failure.

• Blood in the urine -sign of kidney failure 

Behavior

• Change in behavior (such as decreased or increased activity level, incoordination, seizure or aggression)

• Decreased activity level Lethargy, drowsiness—various causes—sedation from the drug, pain from ulcer, anemia from bleeding ulcer; signs of kidney or liver failure due to increased toxins in the blood.

• Staggering, stumbling, seizures, dizziness, loss of balance

• Hyperactivity, restlessness, aggressiveness 

Skin

• Change in skin (redness, scabs, or scratching)

• Pale gums, difficulty breathing, lethargy are signs of anemia from a bleeding ulcer.

• Yellowing of gums, skin, or whites of the eyes (jaundice)  

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Washout period when swtiching meds (current package inserts acknowledge a wash out period, but no longer specify a time period)

Pfizer manufacturer of Rimadyl 2004 insert recommends a 5 to 7 day rest period when changing from one NSAID to another.

"Many dogs are not seen by a veterinarian within the 8-hour window after injury, and these dogs frequently are treated with nonsteroidal anti-inflammatory drugs or large doses of dexamethasone or prednisone before methylprednisolone treatment can be initiated, thus increasing the risk of severe adverse effects." (Olby N (1999) Current Concepts in the Management of Acute Spinal Cord Injury. Journal of Veterinary Internal Medicine: Vol. 13, No. 5 pp. 399–407 last accessed 12/11/07)

"There needs to be an appropriate "washout" period between taking one type of NSAID and switching to another. This is usually 7 days at the minimum and should be coordinated with your veterinarian. Please tell your vet if you have given ANY other medication before being dispensed a NSAID for your pet." Non-steroidal anti-inflammatory use in pets. Sally Suttenfield DVM. May 2005 http://www.fourpawsvetrehab.com/whats_new.html?record=1

Table 1. Washout time when switching to a(nother) NSAID

Caution:

NSAIDs should be approached cautiously in dogs with kidney, liver, heart and intestinal problems.

Never give your dog an NSAID unless directed by your veterinarian.

Don't assume an NSAID for one dog is safe to give to another dog. Always consult your veterinarian before using any medication in your pet.

Only give the NSAID as prescribed by your veterinarian. Do not increase the dose, the frequency, or the length of time you use the drug unless first discussing this with your veterinarian.

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Steroid Side effects/overdosing 

"Glucocorticoid hormones should not be used in combination with medications of the NSAID class (ie aspirin, Rimadyl, Deramaxx, etc.) as the combination of these medications could lead to bleeding in the stomach or intestine. Ulceration could occur.

It is important that the dose be tapered to an every other day schedule once the condition is controlled. The reason for this is that body will perceive these hormones and not produce any of its own.

Side effects: depression, panting, restlessness. Adverse reactions can be: GI irritation, ulceration, pancreatis, vomiting.

Diabetic patients should never take this medication. May also be a problem for heart failure patients or other patients who require sodium restriction." http://www.marvistavet.com/html/body_prednisone.html

"Steroid withdrawal symptoms can mimic many other medical problems. Weakness, fatigue, decreased appetite, weight loss, nausea, vomiting, diarrhea (which can lead to fluid and electrolyte abnormalities), and abdominal pain are common. Blood pressure can become too low, leading to dizziness or fainting. Blood sugar levels may drop." http://www.medicinenet.com/steroid_withdrawal/article.htm

Note: A genetic predisposition for diabetes is suspected in Keeshonds, Puliks, Cairn Terriers, Miniature Pinschers, Poodles, Dachshunds, Miniature Schnauzers, and Beagles. Most dogs are diagnosed between 4 and 14 years old. Any dog suspected of having an insulin related disease, should have tests run before using steroids.

Glucocorticoid Comparison Table

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Dexamethasone, a synthetic glucocorticoid steroid. Dex is approximately 10 times stronger than prednisone/ prednisolone and long acting, but too slow on the onset for a spinal cord injury.

"The use of dexamethasone for treating animals with acute spinal cord trauma is no longer recommended due to doubts about its efficacy and because of its detrimental side effects "Clinical Neurology in Small Animals – Localization, Diagnosis and Treatment, K.G. Braund (Ed.) Traumatic Disorders (6-Feb-2003) http://www.ivis.org/advances/Vite/braund28/IVIS.pdf last accessed 10/15/07

Dexamethasone sodium phosphate use has been replaced by the use of methyl prednisolone sodium succinate (MPSS; Solu Medrol) as the current standard of care in treatment of acute spinal cord injury in the dog. http://www.vetsurg.com/Newsletter2005.html

Historically, dexamethasone has been used to manage spinal cord injury. However, dexamethasone is associated with a much higher incidence of side effects than MPSS. There is no reported beneficial effect of dexamethasone in the management of spinal cord injury! http://www.melbvet.com.au/pdf/disk-disease.pdf

I prefer solumedrol because of studies and in our pharmacy it's cheaper. More vets have Solu delta though, and it's probably just as good. Dexamethasone is less effective at any dose.  (William B. Thomas, DVM, Associate Professor, Neurology &  Neurosurgery, U of Tenn. Veterinary Information  Network Conference.October 1, 2000)

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Solu-Medrol® (Methylprednisolone sodium succinate MPP), a synthetic glucocorticoid steroid

"...methylprednisilone sodium succinate has been considered a "standard of care" in the veterinary management of SCI as it has been in human cases of SCI." JOURNAL OF NEUROTRAUMA Volume 21, Number 12, 2004 p.1775.

"Methylprednisolone succinate (MPS) presently remains the drug of choice in people with acute spinal cord injury due to its neuroprotective effects against the physiological cascade associated with the secondary spinal injury events. These beneficial effects occur when MPS is given within 8 hours of injury. Clinical studies in humans suggest that spinal cord damage may be exacerbated if MPS treatment is initiated more than 8 hours after injury." Clinical Neurology in Small Animals - Localization, Diagnosis and Treatment, K.G. Braund (Ed.) Traumatic Disorders (6-Feb-2003) http://www.ivis.org/advances/Vite/braund28/IVIS.pdf last accessed 10/15/07

"The National Acute Spinal Cord Injury Studies (NASCIS) II and III, a Cochrane review of all randomized clinical trials and other published reports, have verified significant improvement in motor function and sensation in patients with complete or incomplete SCIs who were treated with high doses of methylprednisolone within 8 hours of injury...In the NASCIS III trial, ..the study found that in patients treated earlier than 3 hours after injury, the administration of methylprednisolone for 24 hours was best. In patients treated 3-8 hours after injury, the use of methylprednisolone for 48 hours was best." Spinal Cord Injuries. emedicine last updated Aug 8, 2006. http://www.emedicine.com/emerg/topic553.htm last accessed 10/23/07

Many patients will benefit from corticosteroid management during the initiation of [conservative] treatment. I think this should only be done under direct veterinary supervision. If the patient feels better and then becomes active before healing has occurred, they are at great risk to get worse. We see this outcome commonly. It could be prevented in many cases, with absolute confinement of the patient. Owners do not always comply, allowing their pet to worsen. For that reason, I prefer to treat these patients in the hospital for the first 5-7 days, going home without medication, only confinement. I would give 30 mg/kg of methylprednisolone (Solu Medral or Solu Delta Cortef) IV, initially; followed by 15 mg/kg every 8 hours for the first 24 hours. Then, I give oral prednisolone at 1 mg/kg/day in 2 divided doses for 5 days. If more steroids are needed, I give 0.5 mg/kg every other day in the morning. During steroid medication, it is necessary to protect against steroid-gastritis. I use misoprostil (50-100 µg) every 12 hours until using alternate day steroids. Many patients feel better with muscle relaxants. I prefer diazepam at 0.25-0.5 mg/kg every 8 hours. (R.M. Clemmons, DVM, PhD, Associate Professor of Neurology & Neurosurgery U of FL.PARAPARESIS AND PARAPLEGIA . 1997. http://neuro.vetmed.ufl.edu/neuro/paralysis/para.htm last accessed 12/11/07)

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NSAIDs (non steroidal anti inflammatory drug):

ETOGESIC (etodolac), RIMADYL (carprofen), METACAM (meloxicam), DERAMAXX (deracoxib), PREVICOX (firocoxib), ZUBRIN (tepoxalin), NOVOX (carprofen), ASPIRIN

Although they [NSAIDs] have never been reported to be neuroprotective in spinal cord injury models, there has been a long-standing interest in these drugs because of their potential to block prostaglandin production...None of these drugs have been tested extensively for neuroprotective effects. Experimental Therapies of Spinal Cord Injury. Wise Young, Ph.D., M.D. Last updated 7 January 2002. 

NSAID have minimal benefit in acute spinal cord injury and increase the risk of complications, especially if used in conjunction with corticosteroids. ("Trauma" The Merck Veterinary Manual. © 2006; Merck & Co., Inc.Whitehouse Station, NJ USA.) http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/100713.htm last accessed 11/28/2007

Certain corticosteroids at certain doses may improve recovery from acute spinal cord injury. There is little evidence that NSAIDs are beneficial, other than for mild pain control. (William B. Thomas, DVM, Associate Professor, Neurology & Neurosurgery, U of Tenn. October 1, 2000.Veterinary Information Network Conference.) http://www.ne.jp/asahi/takeuchi-vet/bamboo/page083.html last accessed 11/28/2007

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Prednisone/prednisolone is a synthetic glucocorticoid steroid hormone. Used with Central Nervous System Disorders (usually after trauma or after a disc episode to relieve swelling in the brain or spinal cord). Prednisone is activated by the patient's liver into Prednisolone http://www.marvistavet.com/html/body_prednisone.html 

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Stomach Protectors

• Sucralfate, coats stomach. Give 30 minutes before Pepcid http://www.marvistavet.com/html/body_sucralfate.html Always check with vet.
• Pepcid AC (famotidine) Give 30 minutes before dose of Prednisone http://www.marvistavet.com/html/body_famotidine.html Always check with vet.

Crate Rest

Any dog treated with an antiinflammatory and or pain medications, must be under STRICT crate rest. "If the patient feels better and then becomes active before healing has occurred, they are at great risk to get worse. We see this outcome commonly. It could be prevented in many cases, with absolute confinement of the patient. Owners do not always comply, allowing their pet to worsen. For that reason, I prefer to treat these patients in the hospital for the first 5-7 days, going home without medication, only confinement." (R.M. Clemmons, DVM, PhD, Associate Professor of Neurology & Neurosurgery U of FL.PARAPARESIS AND PARAPLEGIA . 1997. http://neuro.vetmed.ufl.edu/neuro/paralysis/para.htm last accessed 12/11/07)

• The worst thing, I think, is to give pain medication and not ensure cage rest. (William B. Thomas, DVM, Associate Professor, Neurology & Neurosurgery, U of Tenn. October 1, 2000.  Veterinary Information Network Conference. http://www.vmth.ucdavis.edu/vmth/clientinfo/info/neuro/discdis.html
• At UC Davis, animals are usually hospitalized for about 3-10 days after surgery. They are generally discharged from the hospital once they are comfortable and are able to urinate on their own. Once home, the patient's activity is restricted for 4-6 weeks. http://www.vmth.ucdavis.edu/vmth/clientinfo/info/neuro/discdis.html
• “Medical management usually consists of confinement in a cage or pet crate for a minimum of six weeks with minimal movement,” Dr. Chen said. “Pain medication and anti-inflammatory drugs may also be used to control pain. Dr. Chen. Wash St. U. http://www.vetmed.wsu.edu/depts-vth/newsletters/CommPracticespr07.pdf
• "Certain cases with compressive diseases may be managed medically, usually with a combination of strict confinement, analgesics and glucocorticoids. In the author’s experience, NSAIDS are relatively ineffective for nerve root pain, although they may be useful for lesions of the spine itself. " (Dr. Christopher Mariani, DVM, PhD, DACVIM University of Florida. CanWest Veterinary Conference 2007 http://www.canwestconference.ca/proceedings/Chris-Mariani/Neck-and-back-pain–diagnosis-and-treatment.pdf last accessed 12/17/2007

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