Hey Laura!
This is a brilliant question! Balancing the urgency of treating immune-mediated diseases with the potential risks of combining NSAIDs and steroids is indeed challenging.
Ideally, I aim for a 72-hour washout when feasible, although the urgency of some immune-mediated conditions (like IMHA, IMTP, or polyarthritis) often necessitates quicker action with steroids. In certain severe cases, using alternatives like tranexamic acid or vincristine as bridging measures can help delay steroid administration slightly. However, most often, we weigh the risks and proceed with steroid therapy, acknowledging the potential for complications.
Regarding gastroprotection, the evidence supporting prophylactic omeprazole use in preventing GI bleeding in concurrent NSAID-steroid therapy remains limited. A study in the Journal of Veterinary Internal Medicine found that adding omeprazole to prednisone didn’t significantly reduce GI bleeding risk compared to prednisone alone. The study can be accessed here: https://onlinelibrary.wiley.com/doi/pdf/10.1111/jvim.16672. In human medicine, corticosteroid-NSAID combinations are associated with increased GI risk, as shown in a systematic review in BMJ Open available here: https://bmjopen.bmj.com/content/4/5/e004587. Although this data is from human studies, it may indicate similar risks in veterinary patients.
Given the lack of robust veterinary-specific evidence, I reserve omeprazole for cases with GI symptoms rather than routine prophylactic use. Instead, I prioritize hydration, good nutrition, and sometimes probiotics to support the GI tract. For washout, a minimum of 24 hours is often my baseline, extending up to 72 hours when the patient’s condition allows.
Sometimes you just have to hold your nose and give the steroids, I just make sure to carefully council the owners.
Does that make sense?
Scott 🙂
